Hh Monograph

MEASURING
HAND HYGIENE
ADHERENCE:
OVERCOMING
THE CHALLENGES
This monograph was authored by The Joint Commission in collaboration
with the following organizations:
• The Association for Professionals in Infection Control and
Epidemiology, Inc.
• The Centers for Disease Control and Prevention
• The Institute for Healthcare Improvement
• The National Foundation for Infectious Diseases
• The Society for Healthcare Epidemiology of America
• The World Health Organization World Alliance for Patient Safety
This monograph was supported in part by an unrestricted educational grant
provided by GOJO Industries, Inc., Akron, Ohio
The Joint Commission Mission
The mission of The Joint Commission is to continuously improve the safety and quality of care provided to the public
through the provision of health care accreditation and related services that support performance improvement in health
care organizations.
© 2009 The Joint Commission
All rights reserved. No part of this publication may be reproduced in any form or by any means without written permis-
sion from the publisher.
Printed in the U.S.A. 5 4 3 2 1
Requests for permission to make copies of any part of this work should be mailed to:
Division of Quality Measurement and Research
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, Illinois 60181
630-792-5938
The monograph was produced as part of the Consensus Measurement in Hand Hygiene (CMHH) project. The goal of
the CMHH project is to identify promising, practical techniques for measuring adherence to hand hygiene guidelines.
This monograph is the result of a two-year collaboration involving The Joint Commission and six collaborating organiza-
tions: The World Health Organization (WHO) World Alliance for Patient Safety (WAPS), the Association for
Professionals in Infection Control and Epidemiology, Inc. (APIC), the Centers for Disease Control and Prevention
(CDC), the Society for Healthcare Epidemiology of America (SHEA), the Institute for Healthcare Improvement (IHI),
and the National Foundation for Infectious Diseases (NFID). The findings and conclusions in this report are those of the
authors and do not necessarily represent the position of the Centers for Disease Control and Prevention or any of the other
collaborating organizations.
The project was funded in part by an unrestricted educational grant from GOJO Industries, Inc., Akron, Ohio, which
had no involvement in the design, implementation, analysis, results, or review of reports from the project.
Many of the examples included in this monograph come from self-reported methods, tools, and data submitted by
health care organizations to the CMHH project, as well as published literature. Examples included in this monograph are
intended to aid health care organizations in their own hand hygiene efforts and should not necessarily be considered evi-
dence based. Inclusion of any reference or example should not be construed as an endorsement of any measurement method,
product, treatment, or program discussed therein. The inclusion of a vendor, product name, or service should not be con-
strued as an endorsement of such vendor, product, or service, nor is failure to include the name of a vendor, product, or
service to be construed as disapproval.
The CMHH project staff are solely responsible for the monograph content. We have worked to ensure that this mono-
graph contains useful information, but this monograph is not intended to be a comprehensive source of all relevant
information. In addition, because the information contained herein is derived from many sources, the Joint Commission
and its collaborating organizations cannot guarantee that the information is completely accurate or error free. The Joint
Commission and its collaborating organizations are not responsible for any claims or losses arising from the use of, or from
any errors or omissions in, this monograph.
For more information about The Joint Commission, please visit http://www.jointcommission.org.
Executive Summary xvii
Introduction xxi
Purpose and Intended Audience xxi
The Consensus Measurement in Hand Hygiene (CMHH) Project xxi
Why Measuring Adherence to Hand Hygiene Guidelines is Important xxii
Challenges to Measuring Hand Hygiene Adherence: Why it is Not Easy xxii
Scope of this Monograph xxiii
References xxiv
Chapter 1: Hand Hygiene Guidelines: The Foundation for Measurement 1
Factors Influencing Adherence to Hand Hygiene Guidelines 2
Hand Hygiene Indications, Opportunities, and Actions: Understanding the Terminology 2
Key Points, Chapter 1 5
References 5
Chapter 2: Developing a Strategy for Measuring Hand Hygiene 13
Why Do You Want to Measure Hand Hygiene Practices, and What Are Your
Organization’s Goals? 13
What Elements of Hand Hygiene Do You Want to Measure? 13
How Do You Want to Measure Hand Hygiene? 14
Using Multiple Methods to Measure Hand Hygiene 15
Key Points, Chapter 2 16
References 16
Chapter 3: Observing Adherence to Hand Hygiene Guidelines 19
Strengths and Limitations of the Observation Method 19
Components of the Measurement Method 20
Selecting Which Opportunities to Measure 20
Deciding What Aspects to Observe 20
Type of Product or Agent Used 20
Thoroughness of Cleansing 20
Glove Use 21
iii
CONTENTS
Determining Who to Observe 21
Conducting Observations 22
Dealing with “Double Counting” Opportunities 22
Determining When and How Frequently to Observe 22
Determining How Many Observations Are Needed 23
Determining Where to Measure: Structuring and Scheduling Your Observations 24
Selecting a Sample of Health Care Workers or Patients to Observe 24
Determining Who Will Conduct Observations 25
Infection Preventionists 25
Advantages 25
Disadvantage 25
Other Personnel 25
Patients 25
Overt Versus Covert Observation 26
Privacy Considerations 28
Using Technology in Observations 28
Standardizing Observation (Consistency and Reliability) 29
The Importance of Observer Training and Assessing Reliability 29
Documenting Your Methods 29
Determining How to Calculate Adherence Rates 29
Item-by-Item Measures 30
Composite Measures 31
All-or-None Measures 31
Key Points, Chapter 3 32
References 33
Chapter 4: Measuring Product Use 53
Strengths and Limitations of the Product Measurement Method 53
Strengths of Measuring Product Use 53
Limitations of Measuring Product Use 54
Components of the Measurement Method 54
Measuring the Amount of Product Used 54
Measuring the Frequency of Product Use 55
Electronic Counting Devices 55
Electronic Monitoring Systems 57
Estimating Adherence Rates with Product Use Data 58
Customizing Calculations to Specific Units 58
Tools and Systems for Aggregating and Comparing Information 58
Key Points, Chapter 4 60
References 60
Chapter 5: Conducting Surveys 63
Strengths and Limitations of Using Surveys 63
Strengths of Using Surveys 63
Limitations of Using Surveys 64
iv
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Components of Hand Hygiene that Surveys can Assess 64
Staff Knowledge 65
Staff Attitudes and Beliefs 65
Staff Self-Perceptions of Hand Hygiene Behavior 65
Structural Factors and Considerations 66
Patient or Family Satisfaction with Staff Performance 66
Staff Satisfaction with Products 66
Assessment of Skin Condition 66
Key Points, Chapter 5 67
References 67
Chapter 6: Assessing the Thoroughness of Hand Hygiene and Related Aspects 73
Observing Hand Hygiene Technique 73
Physical Measurements of Hand Hygiene 75
Microbiological Methods for Assessing Thoroughness 77
Other Aspects of Hand Hygiene: Nail Length, Artificial Nails, Wearing of Rings,
and Glove Use 78
Nail Length and Artificial Nails 78
Wearing of Rings 80
Monitoring the Use of Gloves 80
Key Points, Chapter 6 81
References 81
Chapter 7: International Hand Hygiene Measurement Tools and Improvement 87
Efforts: Leading the Way to Broadscale Change
Worldwide Efforts: The WHO Global Patient Safety Challenge, “Clean
Care Is Safer Care” 87
WHO Observation Tool 87
National and Regional Efforts 88
England and Wales: “cleanyourhands” Campaign” 88
The Hand Hygiene Observation Tool 88
Ontario, Canada: “Just Clean Your Hands” Program 89
Ontario Observation Tool 89
New South Wales, Australia: “Clean Hands Save Lives” Campaign 90
New South Wales Data Collection Tools 90
Campaign Achievements 90
Health Protection Scotland: “Germs. Wash Your Hands of Them” 91
Data Collection Tools and Auditing Method 91
Campaign Achievements 92
Testing of a Measurement Tool for Use in Developing Countries 92
Key Points, Chapter 7 92
References 92
Chapter 8: Displaying and Interpreting Hand Hygiene Data for Maximum Effectiveness 95
Creating a Hand Hygiene Dashboard 95
Reporting Data by Unit and Type of Health Care Worker 95
Statistical Process Control Charts 95
v
Contents
Associating Process Measures of Hand Hygiene with the Outcome of Infection Rates 96
Key Points, Chapter 8 102
References 103
Chapter 9: Measurement Is Only the Beginning: Factors That Contribute to Improvement 107
Complexity of Changing Behavior 107
Effective Models and Strategies for Hand Hygiene Behavior Change 107
Factors That Affect the Success of Improvement Initiatives 108
Use of Effective Strategies 109
Education and Training 110
Audit and Feedback 110
Reminders 110
Use of Multidisciplinary Teams 110
Systematic Performance Improvement Methods 111
Other Strategies 111
Organizational and System Characteristics 111
Structural Capacity 111
Policies, Procedures, and Processes 111
Leadership 113
Administration Leaders 113
Clinical Leaders: The Importance of Role Models 113
Accountability 114
Leaders of the Improvement Initiative 114
Safety Culture 114
Personnel 114
Staff Engagement 115
Incentives and Rewards 115
Involvement of Patients and Families 115
External Environment 116
What is Success? 116
Key Points, Chapter 9 118
References 119
Chapter 10: Resources for Measurement and Improvement 121
Resources from Organizations Collaborating in Monograph Development 121
Association for Professionals in Infection Control and Epidemiology, Inc. 121
Centers for Disease Control and Prevention 121
Institute for Heathcare Improvement 121
National Foundation for Infectious Diseases 122
Society for Healthcare Epidemiology of America 122
World Health Organization 122
Joint Commission Initiatives 122
International Resources 122
Additional Resources 122
Appendix: Examples of Measurement Tools 129
Index 193
vi
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
LIST OF TABLES
Chapter 1: Hand Hygiene Guidelines: The Foundation for Measurement
— Table 1-1, Barriers to Guideline Adherence
Chapter 4: Measuring Product Use
— Table 4-1, Method for Calculating a Unit-Specific Adherence Rate
Chapter 6: Assessing the Thoroughness of Hand Hygiene and Related Aspects
— Table 6-1, Commonly Used Hand Sampling Methods to Evaluate Hand Hygiene
Chapter 9: Measurement Is Only the Beginning: Factors That Contribute to Improvement
— Table 9-1 Examples of Theoretical Models and Improvement Strategies for Behavior Change in Hand
Hygiene
Chapter 10: Resources for Measurement and Improvement
— Table 10-1, Resources from the Consensus Measurement in Hand Hygiene (CMHH) Project
Collaborators
— Table 10-2, Resources from The Joint Commission, the WHO Collaborating Centre for Patient
Safety, and Joint Commission Resources
— Table 10-3, International Resources
— Table 10-4, Additional Resources
LIST OF FIGURES
Chapter 1: Hand Hygiene Guidelines: The Foundation for Measurement
— Figure 1-1, The World Health Organization’s Five Moments for Hand Hygiene
Chapter 3: Observing Adherence to Hand Hygiene Guidelines
— Figure 3-1, Tripler Army Medical Center Infection Control and Epidemiology Program Manager
Stephen Yamada and Guy Dickinson, Lead Medical Support Assistant, Adult Medicine Clinic,
demonstrate how patients return their hand hygiene observation cards to the receptacle.
Chapter 6: Assessing the Thoroughness of Hand Hygiene and Related Aspects
— Figure 6-1, WHO Diagram of Proper Hand-Washing and Hand Rubbing Techniques
Chapter 8: Displaying and Interpreting Hand Hygiene Data for Maximum Effectiveness
— Figure 8-1, Mock Hand Hygiene Dashboard, First Quarter 2008
Chapter 9: Measurement Is Only the Beginning: Factors That Contribute to Improvement
— Figure 9-1, Factors Affecting the Success of Hand Hygiene Improvement Initiatives
vii
Contents
LIST OF TEXT BOXES
Introduction
— Text Box I-1, CMHH Project Overview
Chapter 2: Developing a Strategy for Measuring Hand Hygiene
— Text Box 2-1, Using Mutiple Methods to Measure Hand Hygiene
Chapter 3: Observing Adherence to Hand Hygiene Guidelines
— Text Box 3-1, Observing Patients
— Text Box 3-2, Avoiding Double Counting
— Text Box 3-3, Sample Observation Schedule
— Text Box 3-4, Engaging Staff to Observe Hand Hygiene
— Text Box 3-5, Patients as Observers of Staff Hand Hygiene
— Text Box 3-6, The Hawthorne Effect
— Text Box 3-7, Using Secret Shoppers in a Hospital
— Text Box 3-8, Interrater Reliability Testing
— Text Box 3-9, Examples of All-or-None Calculation Method
Chapter 4: Measuring Product Use
— Text Box 4-1, Measuring at the Unit or Department Level
— Text Box 4-2, Measuring at the Organizational Level
— Text Box 4-3, Measuring Product Use with Comparative Reports from a Measurement System
Chapter 5: Conducting Surveys
— Text Box 5-1, Examples of Patient Satisfaction Surveys
Chapter 6: Assessing the Thoroughness of Hand Hygiene and Related Aspects
— Text Box 6-1, Examples of Scoring System for Evaluating Hand Hygiene Technique
— Text Box 6-2, Hospitals Monitoring Health Care Workers’ Nails
Chapter 8: Displaying and Interpreting Hand Hygiene Data for Maximum Effectiveness
— Text Box 8-1, Examples of Data Displays Across Different Levels of Analysis
— Text Box 8-2, System-wide Statistical Process Control Charts
— Text Box 8-3, A Hospital That Correlates Health Care–Associated Rates with Hand Hygiene Adherence
Rates
— Text Box 8-4, Challenges to Linking Hand Hygiene Practices and Health Care–Associated Infection Rates
Chapter 9: Measurement Is Only the Beginning: Factors That Contribute to Improvement
— Text Box 9-1, Using Systematic Approaches for Improving Hand Hygiene
— Text Box 9-2, An Example of Visible Commitment
— Text Box 9-3, Accountability of Staff for Hand Hygiene Performance
— Text Box 9-4, Examples of Staff Incentives and Rewards
— Text Box 9-5, Educating Patient and Families
viii
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
LIST OF APPENDIXES
Introduction
— Appendix I-1, Submissions Reviewed by the CMHH Panel
— Appendix I-2, Glossary of Key Terms Used in This Monograph
Chapter 1: Hand Hygiene Guidelines: The Foundation for Measurement
— Appendix 1-1, World Health Organization (WHO) Hand Hygiene Guideline Recommendations: Comparison
with Centers for Disease Control and Prevention (CDC) Guidelines
Chapter 2: Developing a Strategy for Measuring Hand Hygiene
— Appendix 2-1, Components of Hand Hygiene Measurable Within the Three Major Methods
— Appendix 2-2, Overview of Approaches to Measuring Adherence to Hand Hygiene Guidelines
Chapter 3: Observing Adherence to Hand Hygiene Guidelines
— Appendix 3-1, Examples of Research Articles That Compare Adherence Rates on Opportunities for Different
Indications
— Appendix 3-2, Examples of Research Articles That Examine Adherence by Intensity, Frequency, Risk of
Opportunity, and Other Factors
— Appendix 3-3, Examples of Research Articles That Compare Adherence Rates by Category of Health Care Worker
— Appendix 3-4, Examples of Structured Approaches for Observations
— Appendix 3-5, Sampling Approaches
— Appendix 3-6, Examples of Research Articles That Found Evidence of the Hawthorne Effect
Chapter 4: Measuring Product Use
— Appendix 4-1, Studies Examining the Association between Product Measurement and Observation
Chapter 5: Conducting Surveys
— Appendix 5-1, Examples of Hand Hygiene Surveys and Checklists
Chapter 6: Assessing the Thoroughness of Hand Hygiene and Related Aspects
— Appendix 6-1, Examples of Research Articles That Describe Microbiologic Methods for Assessing Hand Hygiene
Technique
Chapter 8: Displaying and Interpreting Hand Hygiene Data for Maximum Effectiveness
— Appendix 8-1, Examples of Studies That Examine the Association Between Hand Hygiene Performance and
Infection Rates
ix
Contents
CONSENSUS MEASUREMENT IN
HAND HYGIENE PROJECT EXPERT
ADVISORY PANEL
Elaine Larson, R.N., Ph.D., F.A.A.N., C.I.C.
Columbia University School of Nursing
Panel Chair and Project Scientific Advisor
Don Goldmann, M.D.
Institute for Healthcare Improvement
Michele Pearson, M.D.
Centers for Disease Control and Prevention
John M. Boyce, M.D.
Hospital of Saint Raphael and Society for Healthcare
Epidemiology of America
Susan J. Rehm, M.D.
National Foundation for Infectious Diseases
Loretta Litz Fauerbach, M.S., C.I.C.
Shands Hospital at the University of Florida and
Association for Professionals in Infection Control and
Epidemiology, Inc.
Brett Higgins, C.H.E.S.P.
Genesis Health System
Didier Pittet, M.D., M.S.
University of Geneva Hospitals and Faculty of Medicine
and WHO World Alliance for Patient Safety
Project staff
Linda Kusek, R.N., B.S.N., M.P.H., C.I.C.
Associate Project Director
Department of Health Services Research
Barbara I. Braun, Ph.D.
Project Director
Department of Health Services Research
Jerod M. Loeb, Ph.D.
Executive Vice President
Division of Quality Measurement and Research
Eve Shapiro, B.S., M.A.
Eve Shapiro Medical Writing, Inc.
Bethesda, Maryland
xi
EXPERT ADVISORY PANEL
AND PROJECT STAFF
The Joint Commission is sincerely appreciative of the many
individuals and organizations that contributed to this
monograph during the various stages of the Consensus
Measurement in Hand Hygiene (CMHH) project. Though
we are sure to miss some, the project staff would like to
specifically acknowledge the contributions of several groups
and persons.
We are grateful to the collaborating organizations that
contributed to all aspects of the project. Those collaborat-
ing organizations are the World Health Organization
(WHO) World Alliance for Patient Safety; the Association
for Professionals in Infection Control and Epidemiology;
the Centers for Disease Control and Prevention; the Society
for Healthcare Epidemiology of America; the Institute for
Healthcare Improvement; and the National Foundation for
Infectious Diseases.
The CMHH project was supported in part by an unre-
stricted educational grant from GOJO Industries, Inc.,
Akron Ohio. Although GOJO had no involvement in
design, implementation, and analysis, results, or review of
reports, we truly appreciate the important role of the
funding organization liaison Michael Dolan, Ph.D., in
making this project possible.
We sincerely thank the members of the expert advisory
panel for their advice, active participation in reviewing
measurement methods and monograph content, as well as
their ongoing support. We were privileged to have interna-
tionally recognized experts who are both sincerely
committed to improving hand hygiene on a broad scale and
a pleasure to work with. In addition to the panel, Hugo Sax,
M.D.; Barry Cookson, M.D., Ph.D.; and Sheldon Stone,
M.D., served as content experts and liaisons for interna-
tional activities. Constance Pachucki, M.D., served as a
representative from the Veterans Administration.
Special thanks go to Elaine Larson, R.N., Ph.D.,
F.A.A.N., C.I.C., who served as scientific advisor and chair
of the panel. Her keen insight and steady guidance kept us
moving forward as we navigated through unanticipated
challenges.
Several practicing infection preventionists and hospital
epidemiologists participated in pilot testing the data collec-
tion survey, specifically Linda Goss, M.S.N., R.N., C.I.C.,
C.O.H.N.-S.; Brenda Grant, R.N., B.S.N., M.P.H., C.I.C.,
C.H.E.S.; Linda Greene, R.N., M.P.S., C.I.C.; Walter
Hellinger, M.D.; Maureen Hodson, R.N., A.S.N., C.I.C.;
Nancy Lumley, M.T.(ASCP), C.I.C.; and Judy Tarselli,
R.N.
We sincerely thank the hundreds of persons in the field
who took the time and effort to submit examples of their
hand hygiene measurement methods for the project, only a
fraction of which are mentioned in this document.
Many reviewers and content experts contributed their
knowledge and expertise to this publication. Included
among these are Claire Kilpatrick, R.N., P.G. Dip., I.C.N.,
M.Sc.; Barbara Soule, R.N., M.P.A., C.I.C.; Vicki
Pritchard, R.N., M.S.; Marvin Bittner, M.D.; Matthew
Koff, M.D.; Daniel Diekema, M.D.; Donna Currie,
M.S.N., R.N.; Jennifer Carpenter, B.S., R.H.I.A.; Robert
Wise, M.D.; Jerod Loeb, Ph.D.; and Julie Storr, B.N.,
R.G.N., R.H.V., M.B.A.
xiii
ACKNOWLEDGMENTS
Last, but definitely not least, several staff in The Joint
Commission Division of Quality Measurement and
Research contributed substantial time and effort to this
project, including Richard Koss, M.A.; Scott Williams,
Psy.D., M.A.; Erica Galvez, M.A.; Nancy Kupka, D.N.Sc.,
M.P.H., M.S., R.N.; Tasha Mearday; Karen Savides; and
Kristine Donofrio.
Thanks also go to Bill Bullerman, B.F.A. for his creative
cover design.
xiv
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Why would anyone write such a lengthy monograph about
measuring adherence to hand hygiene guidelines? More
importantly, why should anyone read it? The practice of
hand hygiene has long been recognized as the most impor-
tant way to reduce the transmission of pathogens in health
care settings. Measuring adherence to hand hygiene practice
is fundamental to demonstrating improvements both at an
organization and a national level.
However, measuring health care worker adherence to
hand hygiene guidelines is not a simple matter. Differing
opinions and misinformation abound. We invite you to
consider whether the following statements are true or false.
1. Everybody knows when to clean their hands.
False. While most of us know when to perform hand
hygiene in our personal lives, health care workers who come
in contact with patients or the patients’ environment are
expected to perform hand hygiene many more times
throughout the encounter. These indications for hand
hygiene are described in professional guidelines and poli-
cies. Within a single encounter with a patient, there can be
several times when hand hygiene should be performed.
Studies show that continuing education is needed to inform
and remind health care workers of the indications for hand
hygiene.
2. It is easy to determine whether a person has
cleaned his or her hands.
False. It may be obvious if someone is performing hand
hygiene, but it is also important to consider how well the
person performs hand hygiene and whether the person used
the appropriate product. A quick rinse under the sink or
brief rub between palms with alcohol-based hand rub may
not be thorough enough to eliminate potential pathogens.
Professional guidelines describe the proper techniques that
should be used as well as when to use soap and water instead
of hand rub.
It is also important to link the action of hand hygiene
with the indications for hand hygiene described in the pro-
fessional guidelines. It is possible that a person performed
hand hygiene when he or she didn’t need to or that the
person did not perform it when needed. Finally, even if you
don’t see a health care worker performing hand hygiene,
consider the fact that it may have been done prior to
coming into the room or outside of your field of vision. You
may want to consider asking a health care worker about it if
you are unsure.
3. People who don’t perform hand hygiene when they
should are careless or lazy or both.
Usually false. The vast majority of health care workers con-
tinually strive to do the right thing and try very hard to
avoid harming patients. As described by Voss and Widmer,
expecting perfection and 100% adherence is unrealistic,
and we must “put an end to the reflex response that health
care workers are neglectful of hand hygiene, which, far from
helping, only demoralizes them further.”
1(p. 208)
Studies have
shown that organizational characteristics such as leadership
involvement, reminders, convenient availability of prod-
ucts, and staff workload have a big influence on hand
xv
FOREWORD
hygiene performance. Health care organizations need to
integrate hand hygiene into routine procedures and have in
place strong systems to support, monitor, and promote the
correct behavior.
4. A hospital that reports a 95% rate of compliance
with hand hygiene guidelines is better than a hospital
that reports 75% compliance.
Unknown (could be true or false). Don’t be misled by sta-
tistics. Unfortunately, there is no standardized method for
collecting and reporting rates of hand hygiene compliance.
Organizations measure compliance in many different ways
and in many different areas of an organization. Some organ-
izations consider each indication for hand hygiene and
sample groups of health care workers throughout the organ-
ization. Others measure more narrowly—for example,
measuring whether hand hygiene was performed before and
after care in the intensive care unit. The compliance rate is
greatly influenced by what indications are chosen for meas-
urement as well as where and how compliance is measured.
As with any other performance measure rate, one should
only compare rates to others that have defined, collected,
and reported the same data in exactly the same way.
5. Observing care is the only way to get a valid assess-
ment of hand hygiene guideline adherence rates.
Not necessarily true. Observation of care has important
advantages, such as allowing you to directly link the activity
of hand hygiene to the indication for hand hygiene.
However, the observation method also has inherent limita-
tions and potential biases (such as the Hawthorne effect, in
which people change behavior because they know they are
being observed). Collecting reliable observation data
requires a highly structured method of both observing care
and documenting data.
2
Other methods, such as measuring
product consumption, have different strengths and weak-
nesses. Using multiple measurement approaches helps to
verify findings. Unfortunately, there is no perfect method
for measuring hand hygiene adherence, and it is important
to acknowledge the limitations of the measurement method
used when rates are reported.
6. Excellent hand hygiene will reduce or eliminate
health care–associated infections.
Partially true. In fact, the Centers for Disease Control and
Prevention and the World Health Organization consider
inadequate hand hygiene to be one of the most important
contributors to infections.
3,4
There are, however, many factors
that influence whether a patient becomes infected. Other
factors include such things as patient severity of illness, equip-
ment and environmental sanitation practices, and adherence
to recommended practices (for example, using maximal
barrier precautions during central line insertions).
We hope these answers have piqued your interest in the
content of this monograph. This monograph is designed to
address the saying “everything you ever wanted to know
about hand hygiene measurement but were afraid to ask”.
Though easy answers are few, we hope this monograph will
broaden your understanding of the issues and provide prac-
tical solutions for strengthening your measurement and
improvement activities. We welcome your comments and
suggestions for improvement.
Sincerely,
The Consensus Measurement
in Hand Hygiene Project Team
REFERENCES
1. Voss A., Widmer A.F.: No time for handwashing!? Handwashing
versus alcoholic rub: Can we afford 100% compliance? Infect
Control Hosp Epidemiol 18:205–208, Mar. 1997.
2. Gould D.J., et al.: Measuring handwashing performance in health
service audits and research studies. J Hosp Infect 66:109–115, Jun.
2007.
3. Centers for Disease Control and Prevention: Guideline for hand
hygiene in health-care settings: Recommendations of the
Healthcare Infection Control Practices Advisory Committee and
the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
MMWR. Morbidity and Mortality Weekly Report 51(RR-16):1–45,
Oct. 25, 2002.
4. World Health Organization (WHO): WHO Guidelines on Hand
Hygiene in Health Care (Advanced Draft): A Summary. Geneva,
Switzerland: WHO, 2006.
xvi
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
HAND HYGIENE MEASUREMENT:
OVERCOMING THE CHALLENGES
This monograph provides a framework to help health care
workers make necessary decisions about what, when, why,
and how they will measure hand hygiene performance. The
monograph also includes resources to help organizations
select the measurement approaches that will best fit their
needs. There are two primary sources of content for this
monograph. The first is examples of methods and tools sub-
mitted through the Consensus Measurement in Hand
Hygiene project. The second is evidence-based guidelines
and published literature.
Following effective hand hygiene practices has long
been recognized as the most important way to reduce the
transmission of pathogens in health care settings. Many
studies, however, have shown that adherence to hand
hygiene recommendations remains low and that improve-
ment efforts frequently lack sustainability. The World
Health Organization (WHO), the Centers for Disease
Control and Prevention (CDC), and others have issued
hand hygiene guidelines for health care workers. Hand
hygiene guidelines specify a wide range of hand hygiene
behaviors, including the following:
• When hand hygiene is indicated
• How to cleanse hands
• What agents to use and how to choose them
• How to dry hands, how long to dry them, and what
instruments to use
• When and how to use disposable gloves
• The wearing of artificial nails and jewelry
• The infrastructure needed to support optimal hand
hygiene
In 2004, The Joint Commission added a National
Patient Safety Goal requiring that accredited health care
organizations comply with hand hygiene guidelines. While
most would agree that hand hygiene is of critical impor-
tance, many have found that measuring adherence to hand
hygiene guidelines is not a simple task. The following are
some of the specific challenges to measuring hand hygiene
adherence:
• Contact with patients or their environment takes place
in many locations within organizations.
• Opportunities for hand hygiene occur 24 hours a day,
seven days a week, 365 days a year and involve both
clinical and nonclinical staff.
• The frequency of hand hygiene opportunities varies by
the type of care provided, the unit, and patient
factors.
• Monitoring is often resource intensive; infection
preventionists, quality improvement staff, and other
health care workers (such as nursing, respiratory
therapy, and so on) face numerous competing
demands for their time and expertise.
• Observer bias (for example, the Hawthorne effect) is
difficult to eliminate (as discussed in Chapter 3).
HAND HYGIENE MEASUREMENT METHODS
Before you select a measurement method, determine the
answers to a few key questions:
xvii
EXECUTIVE SUMMARY
xviii
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
• Why do you want to measure hand hygiene practices,
and what are your organization’s goals?
• What elements of hand hygiene do you want to
measure?
• How do you want to measure hand hygiene?
There are three main methods for measuring hand
hygiene performance, each of which has advantages and dis-
advantages:
• Directly observing
• Measuring product use
• Conducting surveys
Observation involves directly watching and recording
the hand hygiene behavior of health care workers and the
physical environment. Product measurement indirectly
assesses hand hygiene guideline adherence by allowing
health care workers to calculate the amount of liquid soap,
alcohol-based hand rub, and paper towels used in a given
area of the organization. Surveys gather information on
health care worker perceptions, attitudes, and practices
related to hand hygiene, as well as patients’ and families’
attitudes and perceptions of the hand hygiene practices of
health care workers. Using more than one method to
measure hand hygiene performance is likely to yield more
reliable results than using a single method.
Direct Observation
Direct observation of the hand hygiene behavior of health
care workers is considered the “gold standard” of measure-
ment methods. Observation allows you to see which hand
hygiene products are used, the thoroughness of cleansing,
the tools and technique used for drying, the use of gloves,
and whether the staff are performing hand hygiene when-
ever there is an opportunity to do so. This method allows
observers to see who is (and who is not) adhering to guide-
lines and to give prompt feedback when improvement is
needed. In addition, direct observation allows health care
workers to evaluate facility-specific factors that may influ-
ence hand hygiene guideline adherence.
On the other hand, direct observation can be labor
intensive and expensive, requiring the careful selection and
training of those who will observe and record data. Perhaps
the biggest disadvantage of this method is that it can influ-
ence the behavior of those who know they are being
observed.
If you decide to measure adherence to hand hygiene
guidelines using the direct observation method, you first
need to decide who you want to observe; who will conduct
the observations; and when, where, and how often to
observe. The success of this method depends on the accu-
rate calculation of adherence rates, the careful training of
data collectors, and the data collectors’ use of clear, easy-to-
understand forms.
Measuring Product Use
Measuring the amount of liquid soap, alcohol-based hand
rub, and paper towels that health care workers use—and
measuring the frequency with which they use these prod-
ucts—is an indirect way of estimating staff adherence to
hand hygiene guidelines. Measuring product use is less
expensive than observing health care workers directly. It
does not require as many staff members or as much training
as the direct observation method. Measuring product use
can be done at any time and in any place, and it allows you
to track trends in your organization over time. And because
measuring product use is unobtrusive, it is less likely than
the direct observation method to influence health care
workers to change their hand hygiene behavior.
On the other hand, measuring product use does not
reveal whether health care workers are performing hand
hygiene when it is indicated or whether they are performing
it correctly. Measuring product use does not yield any con-
textual information about when or why hand hygiene
guidelines are not adhered to, and it often does not tell you
who is (or isn’t) practicing hand hygiene. In addition, many
factors contribute to making this measurement method
prone to inaccuracy, including product waste or spillage,
product use by patients and family members, and the bor-
rowing of product between units. Because the number of
opportunities for hand hygiene varies widely according to
the setting and patient population, it is important to calcu-
late the adherence rates using realistic numbers of expected
opportunities.
One way to track the amount and frequency of product
use is to manually weigh or measure the amount of liquid
soap or alcohol-based hand rub on a given unit before and
after a prescribed period of time. An alternative is use elec-
tronic counting devices and electronic monitoring systems
to measure the frequency with which these products are
used. In addition to expense, automated systems sometimes
have other shortcomings that can compromise accuracy.
Conducting Surveys
Surveys of health care workers, patients, and family
members—conducted in person, over the telephone, or in
focus groups—can yield information about perceptions,
attitudes, and behavior related to hand hygiene. Deciding
how to administer a survey depends on the number of
people you plan to reach, where they are located, and the
complexity of the sample.
Through surveys, health care workers reveal what they
know and think about hand hygiene as well as why they
adhere (or do not adhere) to guidelines. Surveys can reveal
whether health care workers’ perceptions of their own hand
hygiene behavior match the perceptions of patients and
family members. Using surveys for self-reporting of hand
hygiene behavior can be unreliable; health care workers
tend to overestimate their adherence to guidelines when
questioned and may inaccurately recall their past hand
hygiene behavior.
Using a well-designed and carefully administered
survey whose validity and reliability have been established
can help you achieve the most accurate results possible. It is
important to tailor your survey and the way you administer
it to the population you want to survey and the information
you need to know.
ASSESSING THOROUGHNESS AND OTHER
ASPECTS OF HAND HYGIENE
It is as important to assess the technique with which health
care workers perform hand hygiene as it is to measure when
and how often they perform it. One way to assess and teach
proper technique is to observe the staff periodically to
answer the following questions:
• Are staff members using the proper volume of liquid
soap or alcohol-based hand rub?
• Are they using these products for a sufficient amount
of time?
• Are they avoiding recontamination after hand washing
by using a paper towel to turn off the faucet?
• Are they donning and removing gloves correctly so as
not to contaminate hands?
In addition to exploring answers to these questions, it
can be useful to observe and record information on the
length of health care workers’ fingernails, their wearing of
artificial nails, and their wearing of jewelry. Researchers
have developed detailed data collection methodologies,
audit tools, and scoring systems to help assess these issues as
well as hand hygiene techniques.
INTERNATIONAL HAND HYGIENE
MEASUREMENT TOOLS AND IMPROVEMENT
EFFORTS
There is great global interest in improving adherence to
hand hygiene guidelines. In 2004, The WHO World
Alliance for Patient Safety initiated a global response to the
problem of health care–associated infection, with a major
emphasis on the promotion of hand hygiene in health care.
Many of the measurement and improvement tools devel-
oped for initiatives within and across countries are publicly
available, widely field tested, and well worth considering for
use in your organization.
The international campaigns and initiatives listed here
include rigorously tested and validated tools and training
programs to improve and measure hand hygiene perform-
ance:
• The WHO Global Patient Safety Challenge “Clean
Care Is Safer Care” initiative is available at
www.who.int/gpsc/country_work/application_form/en
/index.html.
• The “cleanyourhands” campaign developed in
England and Wales is available at
www.npsa.nhs.uk/cleanyourhands/the-campaign/. The
National Observational Study to Evaluate the
xix
Executive Summary
“cleanyourhands” Campaign (NOSEC) includes
extensive training materials, including the “Hand
Hygiene Observation Tool” (HHOT), available at
www.idrn.org/nosec.php.
• Information on Ontario, Canada’s “Just Clean Your
Hands” program is available at
www.justcleanyourhands.ca.
• New South Wales, Australia’s “Clean Hands Saves
Lives” campaign is available at:
www.cec.health.nsw.gov.au/pdf/cleanhands/report/app
endix14.pdf.
• Information on Health Protection Scotland’s “Germs.
Wash Your Hands of Them” is available at
www.washyourhandsofthem.com/campaign/campaign
_evaluation.html and
www.scotland.gov.uk/Topics/Health/NHS-
Scotland/19529/2005.
DISPLAYING AND INTERPRETING HAND
HYGIENE DATA FOR MAXIMUM
EFFECTIVENESS
Simple charts and graphs can make data—such as data on
when health care workers clean their hands and how they
clean their hands—easy to interpret and use. A quality
dashboard can provide an organization’s leadership with a
quick, at-a-glance summary of structure, process, and
outcome. It is useful to stratify data by subgroups, such as
specific hand hygiene opportunities or types of health care
workers. Statistical process control charts are useful for
revealing trends in data over time and can help you deter-
mine whether changes in rates are a result of specific
interventions or due to normal variation.
CHALLENGES TO AND STRATEGIES FOR
IMPROVEMENT
It is important to investigate the reasons for non-adherence
to hand hygiene guidelines before deciding on one or more
improvement strategies. It is also useful to examine the
organizational context of health care delivery, which may
facilitate or inhibit adherence. Such organizational factors
include the following:
• The facility’s physical capacity for making products
available
• The presence of written hand hygiene policies and
procedures
• The active involvement of leadership “from the top
down”
• The presence of role models
• The degree of accountability for non-adherent staff
• The presence of a culture of safety
• The active involvement of staff in improvement efforts
• The awareness and involvement of patients and
families
Staff hand hygiene practices can be improved through
efforts such as the following:
• Education
• Timely feedback
• Reminders
• Structured approaches to performance improvement
HAND HYGIENE MEASUREMENT
IMPROVEMENT RESOURCES
The following organizations, which collaborated with The
Joint Commission on this monograph, are resources for
information on improving the measurement of hand
hygiene performance:
• The Association for Professionals in Infection Control
and Epidemiology, Inc. (APIC) (www.apic.org)
• The Centers for Disease Control and Prevention
(CDC) (www.cdc.gov)
• The Institute for Healthcare Improvement (IHI)
(www.ihi.org)
• The National Foundation for Infectious Diseases
(NFID) (www.nfid.org)
• The Society for Healthcare Epidemiology of America
(SHEA) (www.shea-online.org)
• The World Health Organization (WHO)
(www.who.int/gpsc/en/index.html)
xx
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
PURPOSE AND INTENDED AUDIENCE
This monograph provides a framework to help health care
workers make necessary decisions about what, when, why,
and how they will measure hand hygiene performance. It is
intended to meet a frequently expressed need among health
care workers in hospitals, long term care, home care, and
other settings by providing examples of promising practices
for measuring adherence to hand hygiene guidelines. The
monograph also includes helpful resources to assist readers
in selecting the measurement approaches that will best fit
their needs.
There are two primary sources of content for this
monograph. The first is examples of methods and tools
submitted through the Consensus Measurement in Hand
Hygiene (CMHH) Project. The second is evidence-based
guidelines and published literature. The examples of
methods and tools included in this monograph are
intended to aid health care organizations in their own
hand hygiene efforts and should not necessarily be consid-
ered evidence based. Likewise, inclusion of specific
examples, methods, and tools does not constitute endorse-
ment by the monograph’s collaborating organizations.
Although most examples come from U.S. hospitals, the
monograph is intended to be applicable across settings and
countries. Readers wanting additional information on the
examples should refer to Appendix I-1 for submitter
contact information.
The measurement of hand hygiene performance is a
dynamic field with rapidly changing evidence and tech-
niques; therefore, the information presented in this
document should be considered a snapshot as of mid-2008.
This monograph should be regarded as a set of tools for
working on a challenging problem rather than an absolute
solution for success. It is not designed to serve as guidance
for meeting accreditation or regulatory requirements. This
monograph does not address surgical hand hygiene. Key
terms used in the monograph are defined in the glossary
(Appendix I-2).
THE CONSENSUS MEASUREMENT IN HAND
HYGIENE (CMHH) PROJECT
This project, started in the fall of 2006, is the result of a
two-year collaboration involving The Joint Commission
and the following six organizations:
• The World Health Organization (WHO) World
Alliance for Patient Safety (WAPS)
• The Association for Professionals in Infection Control
and Epidemiology (APIC)
• The Centers for Disease Control and Prevention
(CDC)
• The Society for Healthcare Epidemiology of America
(SHEA)
• The Institute for Healthcare Improvement (IHI)
• The National Foundation for Infectious Diseases
(NFID)
The goal of the CMHH project is to identify promis-
ing, practical techniques for measuring adherence to hand
hygiene guidelines. This project, conducted in the Joint
xxi
INTRODUCTION
Commission’s Division of Quality Measurement and
Research, was funded by an unrestricted educational grant
from GOJO Industries. The independent scientific advisor
for the project was Elaine Larson, R.N., Ph.D., F.A.A.N.,
C.I.C., professor of Pharmaceutical and Therapeutic
Research, Columbia University School of Nursing, and pro-
fessor, Columbia University School of Public Health.
WHY MEASURING ADHERENCE TO HAND
HYGIENE GUIDELINES IS IMPORTANT
Following effective hand hygiene practices has long been
recognized as the most important way to reduce the trans-
mission of pathogens in health care settings. Many studies,
however, have shown that adherence to hand hygiene rec-
ommendations remains poor, and improvement efforts
frequently lack sustainability.
2
In 2002, the CDC released updated guidelines
intended to stimulate improvement in hand hygiene prac-
tice throughout the nation.
3
In 2004, The Joint
Commission added a National Patient Safety Goal requir-
ing that health care organizations comply with the CDC
guidelines.
4
In addition, the WHO-WAPS, as part of the
“Clean Care is Safer Care” initiative, developed guidelines
for hand hygiene in 2006.
5
Both the WHO guidelines and
the CDC guidelines recommend that all health care organ-
izations and settings monitor health care workers’ adherence
to hand hygiene recommendations.
CHALLENGES TO MEASURING HAND
HYGIENE ADHERENCE: WHY IT IS NOT
EASY
While most would agree that hand hygiene is of critical
importance, many researchers have found that measuring
adherence to hand hygiene guidelines is not a simple task.
Haas and Larson recently concluded that there is no stan-
dard for measuring adherence to hand hygiene practices, and
each method has advantages and disadvantages: “Without a
standard definition of hand hygiene compliance, and/or lack
xxii
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Text Box I-1.
CMHH Project Overview
The Joint Commission conducted a field survey in
February 2007 to gather standardized information from
organizations that considered their approaches to be potential
examples of effective practice. An expert advisory panel, which
included a representative from each of the collaborating
organizations, identified criteria for evaluating the accuracy
and usefulness of submitted measurement approaches and
tools for possible inclusion in a monograph.
1
The Joint Commission received a total of 242 responses,
representing a variety of settings in 20 countries; 15 of the
respondents voluntarily withdrew, 7 provided no identifiers,
and 117 did not submit the required materials, such as a
submitter’s agreement, examples of tools, and data displays.
Most submissions used observation to measure when hand
hygiene was performed in relation to recommended practice;
slightly less than half measured product consumption; and
fewer (less than one-third) measured thoroughness, glove use,
health care worker satisfaction, or other aspects of hand
hygiene.
Most organizations collected data manually (74.1%), and
some used technology (21.3%). Forty of 103 (38.8%)
complete submissions met basic inclusion criteria (that is, the
measurement method was clearly described, with detailed
collection and reporting instructions and definitions, the
method was used in practice and shown to be feasible, and
accuracy and reliability of the method have been evaluated)
and were reviewed by the expert panel. Most of the submitted
methods had been actively used for a relatively short period of
time; only about 20% reported having used their method for
longer than three years. More than three-quarters of
respondents reported they provided training for data collectors,
but two-thirds of those conducting such training reported the
time spent training was usually less than one hour. Forty-two
percent of respondents reportedly assess the reliability or
validity of the measurement methods they use, but they
supplied little supporting documentation describing their
processes. For additional information on project methods and
findings, see Braun B.I. et al. 2009.
Appendix I-1, “Submissions Reviewed by the CMHH
Panel” lists the sources of the measurement methods reviewed
by the expert advisory panel in 2007.
of standardized methods of training observers, or defining
who should be observers, it is easy to see why reported com-
pliance rates vary considerably across studies.”
6(p. 8)
Few scientific studies have evaluated measurement
techniques; a recent review of the reliability and validity of
hand hygiene measures found that only 28% of research
articles and guidelines related to hand hygiene measure-
ment included any mention of reliability or validity.
7
Methodology between studies varies a great deal, including
how adherence or non-adherence is defined and how obser-
vations are carried out; in addition, sufficient details
concerning the methods and criteria used are often lacking.
8
The following are some of the specific challenges to
measuring hand hygiene adherence:
• Contact with patients and their environment takes
place in many locations within organizations.
• Opportunities for hand hygiene occur 24 hours a day,
7 days a week, 365 days a year and involve both
clinical and nonclinical staff.
• The frequency of hand hygiene opportunities varies by
type of care provided, unit, and patient factors.
• Monitoring is often resource intensive; infection
preventionists, quality improvement staff, and other
health care workers (for example, nursing, respiratory
therapy) face numerous competing demands for their
time and expertise.
• Observer bias (such as the Hawthorne effect) is
difficult to eliminate (as discussed in Chapter 3).
Commenting on the inherent difficulties in measuring
hand hygiene adherence, Marvin Bittner, M.D., VA
Medical Center, Omaha, Nebraska, described the “ideal”
hand hygiene measurement method as one in which “every
health care worker opportunity for hand hygiene is
observed by someone who is invisible, 24 hours a day, 7
days a week, 365 days a year.”
9
Expressing concern about data collection methods,
John Boyce, M.D., section chief of Infectious Diseases and
director of the Hand Hygiene Resource Center at the
Hospital of Saint Raphael in New Haven, Connecticut,
stated that “data from poor tools can be misleading and
dangerous.”
10
Professor Didier Pittet, M.D., M.S., director,
Infection Control Program, University of Geneva Hospitals
and Faculty of Medicine, Geneva, Switzerland, and leader,
WHO First Global Patient Safety Challenge, similarly com-
mented that “a tool used as a standard for hand hygiene
monitoring but providing inaccurate data could produce a
false sense of security among health care workers and, there-
fore, could be counterproductive.”
11
It is noteworthy that several countries or regions have
invested considerable resources in developing and testing
standardized data collection tools and training materials for
hand hygiene in order to assess the effectiveness of broad-
scale improvement initiatives. Many of these materials are
currently or will soon be widely available for use around the
world and should be considered for use by those searching
for ways to improve their measurement strategies. Using
validated methods saves enormous time and resources by
allowing organizations to avoid reinventing the wheel and
provides strategies to obtain better data. This monograph
describes several prominent initiatives.
SCOPE OF THIS MONOGRAPH
The following is a brief overview of the chapters in this
monograph:
• Chapter 1 discusses the CDC and the WHO-WAPS
hand hygiene guidelines; it also describes other
international guidelines. This chapter explains the
difference between hand hygiene indications and
opportunities, and discusses barriers to guideline
adherence.
• Chapter 2 highlights the importance of choosing a
measurement method that meets the particular
organization’s needs and discusses the necessary
components of that assessment process, pointing out
that an organization’s measurement goals should drive
its selection of the measurement method(s).
• Chapters 3 through 5 provide a comprehensive review
of the three main measurement methods, including
the advantages and disadvantages of each
methodology:
— Chapter 3 provides a detailed look at the
observation method of measuring hand hygiene.
The elements of hand hygiene that can be
xxiii
Introduction
measured are described, including issues regarding
when hand hygiene will be observed, which health
care workers will be observed, and who will be
observing. The chapter presents the advantages
and disadvantages of overt versus covert
observation, the importance of observer training
and reliability assessment, and how to calculate
adherence rates/ratios from observational data.
— Chapter 4 reviews measurement of product use,
its advantages and limitations, and the different
ways to go about measuring product use.
— Chapter 5 provides an overview of using surveys
to measure aspects of hand hygiene. The chapter
describes the domains surveys can measure, such
as staff knowledge and staff attitudes and beliefs,
and explores methodological considerations.
• Chapter 6 considers the importance of assessing hand
hygiene thoroughness, nail and jewelry considerations,
and glove use.
• Chapter 7 describes several noteworthy international
hand hygiene measurement initiatives and provides
descriptions of their programs, tools, and methods.
• Chapter 8 explores ways to use and display data. The
chapter also looks at the reasons the link between
hand hygiene practices and health care–associated
infections is difficult to establish.
• Chapter 9 describes the factors that contribute to
improvement in hand hygiene practices and considers
the complexities of changing behavior, as well as some
improvement strategies and interventions.
• Chapter 10 provides an overview of resources from
organizations participating in the project, with a list of
many Web sites that provide valuable information,
tools, and resources on hand hygiene measurement
and improvement.
• The final section, Appendix: Examples of
Measurement Tools, contains selections from several of
the tools described in the monograph.
REFERENCES
1. Braun B.I., Kusek L., Larson E.: Measuring adherence to hand
hygiene guidelines: A field survey for examples of effective
practices. Am J Infect Control, 2009. In press.
2. Haas J.P., Larson E.L.: Compliance with hand hygiene. Am J Nurs
108(8):40–44, 2008.
3. Boyce J.M., Pittet D.: Guideline for Hand Hygiene In Health-
Care Settings: Recommendations of the Healthcare Infection
Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect
Control Hosp Epidemiol 23(Suppl.):S3–S40, Dec. 2002.
4. 2004 JCAHO National Patient Safety Goals approved. Jt Comm
Perspect 23:1–3, Sep. 2003.
5. World Health Organization (WHO) World Alliance for Patient
Safety: WHO Guidelines on Hand Hygiene in Health Care (Advance
Draft). Global Patient Safety Challenge 2005-2006: Clean Care Is
Safer Care. Geneva: WHO, 2006.
6. Haas J.P., Larson E.L.: Measurement of compliance with hand
hygiene. J Hosp Infect 66:6–14, May 2007.
7. Harrington L., et al.: Reliability and validity of hand hygiene
measures. J Healthc Qual 4:20–29, 2007.
8. Boyce J.M., Pittet D.: Guideline for Hand Hygiene In Health-
Care Settings: Recommendations of the Healthcare Infection
Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect
Control Hosp Epidemiol 23(Suppl.):S3–S40, Dec. 2002.
9. Bittner M., VA Medical Center, Omaha, NE, personal
communication, Nov. 8, 2007.
10. Boyce J., Hospital of Saint Raphael, New Haven, CT, personal
communication, Sep. 11, 2007.
11. Pittet D., University of Geneva Hospitals, Geneva, Switzerland,
and leader, World Health Organization First Global Patient Safety
Challenge, personal communication, Jun. 11, 2007.
xxiv
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
xxv
Introduction
Appendix I-1.
Submissions Reviewed by the CMHH Panel
Submitting Organization
Amager Hospital
Copenhagen, Denmark
Amron Corporation
McLean, Virginia
Asante Health System
Medford, Oregon
Brookhaven Memorial Medical Center
Patchogue, New York
CanBeFit Healthcare Consultants
Las Vegas, Nevada
Caritas Norwood Hospital
Norwood, Massachusetts
City of London University
London, England
Denver Health and Hospital
Denver, Colorado
Department of Veterans Affairs
National Center for Patient Safety
Washington, DC
Eastern Maine Medical Center
Bangor, Maine
Ecolab
St. Paul, Minnesota
Greenview Regional Hospital
Bowling Green, Kentucky
Greenville Hospital System
Greenville, South Carolina
Hospital of Central Connecticut
New Britain, Connecticut
Jewish Hospital
Cincinnati, Ohio
Liberty Hospital
Liberty, Missouri
Mayo Clinic
Rochester, Minnesota
McGuckin Methods International (MMI)
Ardmore, Pennsylvania
Health Care Organization Contact
Lisbeth Kyndi Bergen, I.C.N.
e-mail: [email protected]
Sandy Swoboda, R.N., M.S.
Johns Hopkins Hospital
Baltimore, Maryland
e-mail: [email protected]
Susan Binette, R.N., B.S.N.
e-mail:[email protected]
Doreen Virgil, R.N., M.S.N., C.I.C.
e-mail: [email protected]
No healthcare organization contact available
Wanda Carey, R.N., B.S.N., C.I.C.
[email protected]
Dinah Gould, Ph.D., M.Phil., B.Sc., R.N., R.N.T.
e-mail: [email protected]
Connie Savor Price, M.D.
e-mail : [email protected]
Noel Eldridge, M.S.
e-mail: [email protected]
Dina Fenn, R.N., C.I.C.
e-mail: [email protected]
Kathleen Finch R.N., B.S.N., C.I.C.
e-mail: [email protected]
Jennifer Raffaelli, R.N., B.S.N., C.I.C.
e-mail: [email protected]
Susan Boeker, R.N., B.S.N., C.I.C.
e-mail: [email protected]
Lynn Pepin, R.N., C.I.C.
e-mail: [email protected]
Azalea Wedig, B.S., I.P.
e-mail: [email protected]
Jo Micek, R.N., C.I.C.
e-mail: [email protected]
Linda J. Grupa, M.P.H., R.N., B.S.N.
e-mail: [email protected]
Karen Ray, M.T., C.I.C.
Upper Chesapeake Medical Center
Bel Air, Maryland
e-mail: [email protected]
Focus of Method
Technique: UV light, fluorescent ABHR
Electronic monitoring
Observation
Observation and measuring product use
Technique: pH meter
Measuring product use
Observation
Observation
Observation, measuring product use, and
health care worker survey
Observation and measuring product use
Measuring product use
Observation
Observation, measuring product use, and
patient survey
Observation
Observation
Observation
Observation
Measuring product use
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix I-1. (continued)
Meritech, Inc.
Golden, Colorado
Michigan Hospital Association
Keystone Center
Lansing, Michigan
Ministry of Health and Long-term Care
Ontario, Canada
Park Nicollet Methodist Hospital
St. Louis Park, Minnesota
Reedsburg Area Medical Center
Reedsburg, Wisconsin
Royal Free and University College Medical School
London, England
Saint Claire's Hospital
Weston, Wisconsin
Shriners Hospital for Children
Chicago, Illinois
Spartanburg Regional Health care System
Spartanburg, South Carolina
Sprixx
Santa Barbara, California
St. Joseph Health Care
Lexington, Kentucky
Tripler Army Medical Center
Honolulu, Hawaii
UH Case Medical Center
Cleveland, Ohio
UltraClenz, LLC
Riviera Beach, Florida
University Community Hospital
Tampa, Florida
University of Louisville
Louisville, Kentucky
VA Medical Center
Omaha, Nebraska
Versus Technology, Inc.
Traverse City, Michigan
World Health Organization -World Alliance for
Patient Safety
Geneva, Switzerland
No healthcare organization contact available
Kimberly Sepulvado, R.N.
e-mail: [email protected]
Tiffany Jay
e-mail: [email protected]
Amy Priddy, M.S., R.N., C.I.C.
e-mail: [email protected]
Rita Schara, R.N., B.S.N.
e-mail: [email protected]
Sheldon Stone, B.Sc., M.D., F.R.C.P.
e-mail: [email protected]
Paul J. Thomas, R.N., B.S.N., C.I.C.
e-mail: [email protected]
Kim Romberg, R.N., C.I.C.
e-mail: [email protected]
Kathy Bryant, R.N., C.I.C.
E-mail: [email protected]
Matthew D. Koff, M.D., M.S.
Dartmouth-Hitchcock Medical Center
Lebanon, Hew Hampshire
e-mail: [email protected]
Dana Stephens, M.T., C.I.C.
e-mail: [email protected]
Stephen Yamada, M.S., C.I.C.
e-mail: [email protected]
Christine Sydenstriker, R.N., B.S.N.
e-mail: [email protected]
Barbara Franklin
Dana-Farber Cancer Institute
Boston, Massachusetts
e-mail: [email protected]
Jacqueline Whitaker, R.N., M.S., C.I.C.
e-mail: [email protected]
Linda Goss, M.S.N., R.N., C.I.C., C.O.H.N.-S.
e-mail: [email protected]
Marvin J. Bittner, M.D., M.Sc.
e-mail: [email protected]
No healthcare organization contact available
Claire Kilpatrick, R.N., P.G. Dip., I.C.N., M.Sc.
e-mail: [email protected]
Automated hand wash stations,
RFID badges
Observation
Observation
Observation
Observation
Observation
Observation
Observation
Observation
Measuring product use
Observation and patient survey
Observation (by patients)
Observation
Electronic hand wash system
Observation and measuring product
use
Observation
Measuring product use
Measuring product use
Observation and survey
xxvi
xxvii
Introduction
Appendix I-2.
Glossary of Key Terms Used in This Monograph
Term
Adherence
1,2
Bias
3
Alcohol-based hand rub
(ABHR)
4
Antimicrobial soap
4
Antiseptic agent
4
Antiseptic hand rubbing
4
Antiseptic hand washing
4
Clinical guideline
5
Compliance
1,2
Confounding
3
Confounder, Confounding
variable
6
Hand
antisepsis/decontamination
4
Hand cleansing
4
Hand hygiene
4
Hand washing
4
Health care–associated infection
7
Definition
Similar to compliance, the extent to which behavior matches agreed recommendations or guidelines. This
term has been adopted by many as an alternative to compliance in an attempt to emphasize that an
individual is free to decide whether to adopt the recommended behavior.
A systematic deviation of a study’s result from a true value. Typically, it is introduced during the design or
implementation of a study and cannot be remedied later.
An alcohol-containing preparation (liquid, rinse, gel, or foam) designed for application to the hands to
reduce the growth of microorganisms. Such preparations may contain one or more types of alcohol with
excipients, other active ingredients, and humectants.
Soap (detergent) containing an antiseptic agent at a concentration that is sufficient to reduce or inhibit the
growth of microorganisms.
An antimicrobial substance that reduces or inhibits the growth of microorganisms on living tissues.
Examples include alcohols, chlorhexidine gluconate, chlorine derivatives, iodine, chloroxylenol (PCMX),
quaternary ammonium compounds, and triclosan.
Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms without the need for
an exogenous source of water and requiring no rinsing or drying with towels or other devices.
Washing hands with water and soap or other detergents containing an antiseptic agent.
A systematically developed statement for practitioners and participants about appropriate health care for
specific clinical situations.
The extent to which behavior matches or conforms to recommendations or guidelines.
A situation in which relations are factually right but cannot be interpreted causally because some
underlying, unaccounted-for factor is associated with both exposure and outcome.
A factor that distorts the true relationship of the study variables of central interest by virtue of being
related to the outcome of interest but extraneous to the study question and unequally distributed among
the groups being compared. For example, age might confound a study of the effect of a toxin on longevity
if individuals exposed to the toxin were older than those not exposed.
Reduction or inhibition of the growth of microorganisms through the application of an antiseptic hand
rub or through antiseptic hand washing.
Performing hand hygiene for the purpose of physically or mechanically removing dirt, organic material, or
microorganisms.
A general term referring to any action of hand cleansing.
Washing hands with plain or antimicrobial soap and water.
A localized or systemic condition resulting from an adverse reaction to the presence of an infectious
agent(s) or its toxin(s) that occurs in a patient who is in or was in a health care setting (for example,
hospital, outpatient clinic) and was not present or incubating at the time of admission unless the infection
was related to a previous admission to the same setting.
xxviii
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix I-2. (continued)
1. Adapted from Horne R.: Compliance, adherence and concordance: Implications for asthma treatment. Chest. 130(1 Suppl.):65S–72S, 2006.
2. Aronson J.K.: Editors’ view: Compliance, concordance and adherence. Br J Clin Pharmacol 63(4):383–384, 2007.
3. Vandenbroucke J.P., et al.: Strengthening the reporting of observational studies in epidemiology (STROBE): Explanation and elaboration. Ann Intern Med
147:W-163–W-194, 2007.
4. Adapted from World Health Organization (WHO): WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary. Geneva: WHO, 2006.
5. The Cochrane Collaboration: Glossary of Cochrane Collaboration and Research Terms. http://www.cochrane.org/resources/glossary.htm. Accessed Sep. 8, 2008.
6. Journal of the American Medical Association glossary of methodologic terms. http://jama.ama-
assn.org/content/vol295/issue1/images/data/103/DC4/JAMA_auinst_term.dtl. Accessed Oct. 29, 2008.
7. Adapted from McKibben L., et al.: Guidance on public reporting of healthcare-associated infections: Recommendations of the Healthcare Infection Control
Practices Advisory Committee. Am J Infect Control 33:217–226, 2005.
8. Adapted from Centers for Disease Control and Prevention: Influenza vaccination of health-care personnel: recommendations of the Healthcare Infection
Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP). MMWR. 55(RR-2):[inclusive page
numbers], 2006.
9. World Health Organization (WHO) World Alliance for Patient Safety: Manual for Observers. Geneva, Switzerland: WHO, 2006.
10. APIC Press Release dated July 10, 2008.
11. Cohen J.: A coefficient of agreement for nominal scales. Educational and Psychological Measurement 20(1):37–46, 1960.
12. Fleiss J.L.: Statistical Methods for Rates and Proportions, 2nd ed. New York: Wiley, 1981.
Health care worker
8
Indication
9
Infection Preventionist
10
Kappa statistic
11,12
Opportunity
9
Visibly soiled hands
4
In this monograph, synonymous with the term health care personnel, which was defined by the Healthcare
Infection Control Practices Advisory Committee (HICPAC) to include all paid and unpaid persons working
in health care settings who have the potential for exposure to infectious materials, including body
substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or
contaminated air. These include (but are not limited to) physicians, nurses, nursing assistants, therapists,
technicians, emergency medical service personnel, dental personnel, pharmacists, laboratory personnel,
autopsy personnel, students and trainees, contractual staff not employed by the health care facility, and
persons (for example, clerical, dietary, housekeeping, maintenance, and volunteer personnel) not directly
involved in patient care but potentially exposed to infectious agents that can be transmitted to and from
health care personnel or patients.
The reason hand hygiene is necessary at a given moment. It is justified by a risk of germ transmission from one
surface to another. It is formulated in terms of a temporal reference point, such as “before” or “after” contact.
Infection preventionists direct interventions that protect patients from healthcare-associated infections (HAIs)
in clinical and other settings around the world. They work with clinicians and administrators to improve
patient and systems-level outcomes and reduce HAIs and related adverse evens. (Formerly known as Infection
Control Professionals prior to July 10, 2008.)
Cohen’s statistical measure of interrater agreement, which is generally thought to be a more robust measure
than simple percent agreement calculation because it takes into account the agreement occurring by
chance. Kappa measures the agreement between two raters who each classify N items into C mutually
exclusive categories.
The equation for K is K = Pr(a) – Pr(e)
1 – Pr(e)
where Pr(a) is the relative observed agreement among raters, and Pr(e) is the hypothetical probability of
chance agreement. If the raters are in complete agreement, then K = 1. If there is no agreement among the
raters (other than what would be expected by chance), then K < 0.
For most purposes, K > .75 can be considered to represent excellent agreement beyond chance, K < .40 can
be considered to represent poor agreement beyond chance, and K > .40 and < .75 can be considered to
represent fair to good agreement beyond chance.
Whenever one of the indications for hand hygiene is present and observed. Each opportunity should
correspond to an action.
Hands on which dirt or body fluids are readily visible.
Guidelines for hand hygiene are intended to promote
improved hand hygiene practices that help health care insti-
tutions reduce transmission of microorganisms and the
associated infections, which lead to increased morbidity,
mortality, lengths of stay, and costs. The guidelines consist
of specific recommendations that are based on scientific evi-
dence and the consensus of experts in the field.
1,2
Adhering
to hand hygiene guidelines is the most effective way to
prevent health care–associated infections, particularly in
hospital intensive care units and neonatal intensive care
units, where adherence to hand hygiene guidelines tends to
be lowest and patient vulnerability to infection tends to be
highest.
1,3,4
Guidelines for hand hygiene have been issued by many
organizations and countries, and they are revised periodi-
cally as new evidence becomes available. It is important,
therefore, to always refer to the primary issuing source in
order to access the most recent version of a guideline. Some
examples of hand hygiene guidelines and related documents
include those issued by the following:
• Health Canada
5
• The Centers for Disease Control and Prevention
(CDC), United States
1
• The Department of Health and Aging, Australia
6
• National Health Service, England
7
• The World Health Organization (WHO)
2
The hand hygiene guidelines listed here all address the
core elements of hand hygiene behaviors, including the fol-
lowing:
• When to perform hand hygiene
• Agents to use in hand hygiene
• Techniques for hand hygiene (depending on the
agents used)
• Duration of hand hygiene
• Technique, duration, and instruments for drying
hands
• Use of disposable gloves
• Wearing of artificial nails and jewelry
• How to choose hand hygiene agents
• The necessary infrastructure for optimal hand hygiene
There is a great deal of similarity across existing hand
hygiene guidelines, but there are some differences as well.
For example, single-use disposable paper towels are recom-
mended for drying hands in all the guidelines, but the
Australian guidelines also state that a clean cloth towel, a
fresh portion of a roller towel, and use of retractable hand
towels is acceptable.
6
Glove use is another area in which
there is some variation among guidelines. All the guidelines
recommend against the reuse of gloves. The WHO guide-
lines state: “Avoid reuse of gloves. If gloves are reused,
implement reprocessing methods to ensure glove integrity
and microbiological decontamination.”
2(p. 98)
Differences
among guidelines are often appropriate because of differ-
ences in the intended users of the guidelines.
There are also differences in the way guideline issuers
categorize, or grade, the evidence that supports their recom-
mendations. Appendix 1-1 presents a comparison of the
CDC and WHO hand hygiene guidelines.
1
chapter 1
HAND HYGIENE GUIDELINES:
THE FOUNDATION FOR MEASUREMENT
FACTORS INFLUENCING ADHERENCE TO
HAND HYGIENE GUIDELINES
Individual clinician adherence to safe hand hygiene prac-
tices is low worldwide, despite evidence that adhering to
guidelines reduces infections.
1,2,4,8,9
This lack of adherence
has led to improvement initiatives by the WHO and The
Joint Commission’s issuance of National Patient Safety Goal
7,
10
which calls for health care organizations to follow the
CDC hand hygiene guidelines; National Patient Safety
Goal 7 was expanded in 2008 to also include the WHO
hand hygiene guideline.
11
Table 1-1 lists some of the factors associated with low
adherence to hand hygiene guidelines. In addition to factors
listed in Table 1-1, Sax et al. pointed out that poor health
care worker training on why, when, and how to perform
hand hygiene during routine care is also a barrier to proper
hand hygiene.
12
HAND HYGIENE INDICATIONS,
OPPORTUNITIES, AND ACTIONS:
UNDERSTANDING THE TERMINOLOGY
The effective measurement of hand hygiene adherence
requires an understanding of some basic terminology asso-
ciated with the hand hygiene process. Three of the most
important concepts are indications, opportunities, and
actions.
Indications are the principal rationale for performing
hand hygiene. Developers of hand hygiene guidelines define
indications and incorporate them into written guidelines
1,13
;
in turn, individual health care organizations can incorporate
the guidelines into their written policies governing hand
hygiene.
According to the WHO Manual for Observers, an indi-
cation “is the reason why hand hygiene is necessary at a
given moment. It is justified by a risk of germ transmission
from one surface to another. It is formulated in terms of a
temporal reference point: ‘before’ and ‘after’ the contact.
The indications ‘before’ and ‘after’ do not necessarily corre-
spond to the beginning and completion of a care sequence
or activity. They occur during movements between geo-
graphical areas, during transitions between tasks near
patients, or some distance from them.”
13(p. 7)
Some examples of indications for hand hygiene in both
the CDC and WHO guidelines include the following:
• Before patient contact
• Before starting an invasive procedure
• After contact with blood, body fluids or excretions,
mucous membranes, non-intact skin, and wound
dressings
• After removing gloves
• When moving from a contaminated patient body site
to a clean site during care
• After contact with inanimate objects or medical
equipment close to the patient
• After patient contact
When choosing a tool to measure hand hygiene
adherence, it is important to be clear about which indica-
tions you want to capture. The WHO guidelines
recommend that five indications be measured.
2
These five
indications, which the WHO refers to as moments, are pre-
sented in Figure 1-1.
Opportunities represent the points in time within the
care process when hand hygiene should be performed, as
specified by the indications. An opportunity exists when-
ever at least one of the indications for hand hygiene is
present and observed
13
; however, there can be more than
one indication for a single opportunity. For example, say
that a nurse completes a dressing change, removes the
gloves, and leaves the patient room. The indications are (1)
after contact with wound dressings, (2) after removing
gloves, and (3) after patient contact. All three indications
apply to one opportunity or expectation that hands should
be cleaned.
Actions comprise the performance of hand hygiene.
Each opportunity should correspond to an action of per-
forming hand hygiene. “If properly carried out, the hand
hygiene action implies recognition of the indications by
healthcare workers during their activities and within the
process they organize care.”
13(p. 8)
2
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
A broad array of measurement approaches that can be
applied to hand hygiene are discussed in the following chap-
ters. The first step in determining which measurement
approach will work best for you is to develop a strategy for
measurement; this is the focus of Chapter 2.
3
Hand Hygiene Guidelines: The Foundation for Measurement
Table 1-1.
Barriers to Guideline Adherence
Source: Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the
Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
MMWR. 51(RR- 16):[inclusive page numbers], 2002.
4
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Figure 1-1.
The World Health Organization’s Five Moments for Hand Hygiene
Source: World Health Organization (WHO): WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary.
Geneva, Switzerland: WHO, 2006.
KEY POINTS, CHAPTER 1
• Guidelines establish the recommended
practices against which performance should
be measured.
• Although hand hygiene guidelines have been
issued by several organizations and countries,
most recommendations are consistent across
guidelines.
• Indications are the principal rationale for
performing hand hygiene.
• Opportunities represent the points in time
within the care process when hand hygiene
should be performed, as specified by the
indications.
• A hand hygiene action should be performed
whenever an opportunity for hand hygiene
exists.
REFERENCES
1. Boyce J.M., Pittet D.: Guideline for Hand Hygiene In Health-
Care Settings: Recommendations of the Healthcare Infection
Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect
Control Hosp Epidemiol 23(Suppl.):S3–S40, Dec. 2002.
2. World Health Organization (WHO): WHO Guidelines on Hand
Hygiene in Health Care (Advanced Draft): A Summary. Geneva,
Switzerland: WHO, 2006.
3. Pittet D., Mourouga P., Perneger T.V.: Compliance with
handwashing in a teaching hospital. Ann Intern Med
130(2):126–130, 1999.
4. Lam C.C., Lee J., Lau Y.L.: Hand hygiene practices in a neonatal
intensive care unit: a multimodal intervention and impact on
nosocomial infection. Pediatrics 114(5):e565–e571, 2004.
5. Health Canada: Infection Control Guidelines: Hand Washing,
Cleaning, Disinfection and Sterilization in Health Care. Ottawa,
Canada; Health Canada, Laboratory Centre for Disease Control,
Bureau of Infectious Diseases, Nosocomial and Occupational
Infections. http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/98pdf/cdr24s8e.pdf. Dec. 1998.
6. Australian Government, Department of Health and Ageing:
Infection Control Guidelines for the Prevention of Transmission of
Infectious Diseases in the Health Care Setting.
http://www.health.gov.au/internet/main/publishing.nsf/Content/ic
g-guidelines-index.htm. Canberra, Australia: Australian
Government, Department of Health and Ageing, 2004.
7. Pratt R.J., et al.: National Evidence-Based Guidelines for Preventing
Healthcare-Associated Infections in NHS Hospitals in England.
London: Research Wells Research Centre, Thames Valley
University, 2006.
8. Pittet D.: Compliance with hand disinfection and its impact on
hospital-acquired infections. J Hosp Infect 48 (Suppl. A):S40–S46,
2001.
9. Rosenthal V.D., Guzman S., Safdar N.: Reduction in nosocomial
infection with improved hand hygiene in intensive care units of a
tertiary care hospital in Argentina. Am J Infect Control
33:392–397, 2005.
10. 2004 JCAHO National Patient Safety Goals approved. Jt Comm
Perspect 23:1–3, Sep. 2003.
11. The Joint Commission announces the 2008 National Patient
Safety Goals and requirements. Jt Comm Perspect 27:1, 9–22, Jul.
2007.
12. Sax H., et al.: My five moments for hand hygiene: A user-centred
design approach to understand, train, monitor and report hand
hygiene. J Hosp Infect 67(1):9–21, Sep. 2007.
13. World Health Organization (WHO), World Alliance for Patient
Safety: Manual for Observers. Geneva, Switzerland: WHO, 2006.
5
Hand Hygiene Guidelines: The Foundation for Measurement
6
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 1-1.
World Health Organization (WHO) Hand Hygiene Guideline Recommendations:
Comparison with Centers for Disease Control and Prevention (CDC) Guidelines
Recommendation
A. Visible dirt, blood or body
fluids on hands of health
care worker (HCW)
B. No visible dirt, blood, or
body fluids on hands of
HCW in the following
clinical situations:
1. Before direct patient
contact
2. After removing gloves
3. Before handling invasive
device for insertion
4. After contact with blood,
body fluids, mucous
membranes, non-intact
skin, and wound dressings
5. Moving from
contaminated patient
body site to clean site
during patient care
6. After contact with
inanimate objects or
medical equipment close
to patient
C. Potential exposure to spore-
forming organisms
CDC Guideline*
A. (IA) Non-antimicrobial or
antimicrobial soap and water
B. (IA) Prefer alcohol hand rub
or, alternatively, (IB)
antimicrobial soap and water
1. (IB) Recommend
2. (IB) Recommend
3. (IB) Before donning sterile
gloves for central venous
catheter insertion; also for
insertion of other invasive
devices that do not require
a surgical procedure using
sterile gloves
4. (IA) Recommend
5. (II) Recommend
6. (II) Recommend
C. (II) Non-antimicrobial or
antimicrobial soap and
water
WHO Guideline*
A. (IB) Soap and water
B. (IA) Prefer alcohol hand rub
or, alternatively, (IB) soap
and water
1. (IB) Recommend before
and after contact
2. (IB) Recommend
3. (IB) Before insertion of all
invasive devices, regardless
of glove use
4. (IA) Recommend
5. (IB) Recommend
6. (IB) Recommend
C. (IB) Soap and water
Key Points of WHO Guideline
Simplifies terminology and does
not differentiate between non-
antimicrobial and antimicrobial
soap, unless specified
Clarifies expanded use of hand
hygiene
Clarifies clinical situations and
simplify terminology
Alcohol hand rub is ineffective
against spore-forming organisms
(e.g., Clostridium difficile,
Bacillus anthracis)
I. Indications for handwashing and hand antisepsis
7
Hand Hygiene Guidelines: The Foundation for Measurement
Appendix 1-1. (continued)
D. After using restroom
E. Before handling medication
or food
F. Concomitant or sequential
use of alcohol rub with soap
and water
A. Alcohol hand hygiene rub
B. Handwashing with soap and
water. Wet hands first, wash
thoroughly, rinse, dry with
disposable towel, and use
towel to turn off faucet
C. Avoid use of very hot water
to decrease risk of dermatitis
D. Dry hands thoroughly after
hand hygiene
E. Avoid using multiuse (cloth)
hand towels
F. Use of antimicrobial-
impregnated wipes as hand
hygiene alternative
D. (IB) Non-antimicrobial or
antimicrobial soap and
water
E. (IB) Non-antimicrobial or
antimicrobial soap and water
(before handling food)
F. No comment in non-surgical
setting. In surgical (operating
room) setting, recommend
pre-washing hands with soap
and water before alcohol rub
(see III.G.2 below)
A. (IB) Apply palmful, rub
thoroughly until dry. Follow
manufacturer’s
recommendation regarding
volume of product to use
B. (IB) Wash for 15 seconds
C. (IB) Recommend
D. Recommend (see II.A and
II.B above)
E. (II) Recommend
F. (IB) May use as alternative to
non-antimicrobial soap and
water. Do not use as
alternative to antimicrobial
soap and water or to alcohol
hand rub
D. (II) Soap and water
E. (IB)Alcohol rub or soap and
water (before handling both
medication and food)
F. (II) Not recommended in
either nonsurgical or surgical
setting
A. (IB) Apply palmful, rub
thoroughly until dry. See
instructional diagram
B. (IB) Wash using vigorous
rotational handrubbing
technique. No time
requirement. See
instructional diagram
C. (IB) Recommend
D. Recommend; separate
emphasis
E. (IB) Recommend
F. No comment
Recommends alcohol rub and
expands recommendation to
include medication
Prewashing hands is not
recommended
Emphasizes hand hygiene
technique rather than product
volume and refers to diagram
Emphasizes hand hygiene
technique rather than time
requirement and refers to
diagram
Emphasizes CDC recommenda-
tion regarding non-reuse of cloth
towels by individuals
Recommendation CDC Guideline* WHO Guideline* Key Points of WHO Guideline
II. Hand hygiene technique (non-surgical)
8
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 1-1. (continued)
G. Use of bar, liquid, leaf or
powder soaps. May use if
using non-antimicrobial soap
and water. Bar soap should
be small size and sit on
drainage rack
A. Remove of visible dirt before
preparation
B. Clean fingernails using nail
cleaner before preparation
C. Design handwashing sink to
minimize splashing
D. Remove rings, watches, and
bracelets before preparation
E. Artificial nails prohibited
F. Type of surgical hand prepara-
tion: either antimicrobial soap
and water or sustained activity
alcohol rub
G. Duration and technique of
surgical hand preparation
1. If using antimicrobial
soap and water
2. If using alcohol rub
G. (II) Recommend
A. No comment
B. (II) Recommend
C. No comment
D. (II) Recommend
E. Recommend; for high-risk
patients (e.g., in intensive
care unit or operating room)
F. (IB) Recommend
1. Manufacturer’s
recommendation; usually
2 to 6 minutes
2. (IB) No time
requirement. Prewash
hands with non-
antimicrobial soap and
water
G. (II) Recommend
A. (II) Wash hands with soap
and water
B. (II) Recommend; clean
under running water
C. (II) Recommend
D. (II) Recommend
E. (IA) Recommend; for direct
contact with all patients
F. (IB) Recommend; if water
quality is not assured, use
alcohol rub
1. Manufacturer’s
recommendation; usually
2 to 5 minutes
2. (IB) No time requirement.
Apply to dry hands and
keep hands and forearms
wet during application.
Do not pre-wash hands or
use alcohol rub and soap
and water concomitantly
or sequentially
Emphasizes removal of visible
dirt prior to surgical preparation
Recommends evaluating sink
design; faulty faucet aerators have
been associated with contamina-
tion of handwashing water
Expands prohibition of artificial
nails; associated with changes in
normal flora and impede proper
hand hygiene
Some areas may have water
quality problems
Prewashing hands not
recommended (see I.F above)
Recommendation CDC Guideline* WHO Guideline* Key Points of WHO Guideline
III. Surgical hand preparation
9
Hand Hygiene Guidelines: The Foundation for Measurement
Appendix 1-1. (continued)
H. Allow hands to dry
thoroughly before gloving
A. Administrative Actions
1. Provide HCWs with
efficacious (effective)
product that is less likely
irritate
2. Maximize acceptance and
solicit input from HCWs,
and include cost as factor
in product selection
3. Consult manufacturer’s
recommendation
regarding possible
interaction between (a)
product and gloves, and
(b) product and creams or
lotions
B. Dispensers
1. Access by HCWs:
location of dispensers. For
alcohol rub: recommend
individual pocket-sized
containers for HCWs
2. Function and deliver
specified product volume
3. Alcohol rub product
dispenser approved for
flammable materials
4. Adding soap to partially
filled dispensers for refill
I. (IB) Recommend
1. (IB) Recommend
2. (IB) Recommend
3. a. (II) Recommend
b. (IB) Recommend
1. Refers to alcohol rub
dispensers only; accessible
at entrance to patient’s
room, at bedside, or other
convenient locations
2. (II) Recommend
3. (IC) Dispenser not
specified but must store
dispensers in cabinets
approved for flammable
materials
4. (IA) Not recommended
I. (IB) Recommend
1. (IB) Recommend
2. (IB) Recommend
3. a. (II) Recommend
b. (IB) Recommend
1. (IB) Refers to both soap
and alcohol rub
dispensers; accessible at
point of care
2. (II) Recommend
3. (IC) Dispenser must be
approved for flammable
materials
4. (IA) Not recommended
Clarifies terminology and
encourage flexibility in location
Clarifies flammability
requirements for individual
dispensers
Clean soap dispensers
thoroughly before refilling to
avoid bacterial contamination
Recommendation CDC Guideline* WHO Guideline* Key Points of WHO Guideline
IV. Selection of hand hygiene agents
10
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 1-1. (continued)
C. Skin Care
1. Educate HCWs regarding
hand hygiene practices
that can reduce the risk of
contact dermatitis and
provide creams and
lotions
A. Gloves are not a substitute
for hand hygiene
B. Use gloves before contact
with blood and body fluids,
mucous membranes and
non-intact skin
C. Remove gloves after contact
with each patient and avoid
re¬use of gloves
D. Change or remove gloves if
moving from contaminated
to clean patient site or the
environment
A. Use of artificial
nails/extenders
B. Nail length (natural nails);
tips must be less than 1/4
inch, or 0.5 cm, in length
C. Wearing of rings in
nonsurgical health care
settings
A. Monitoring of hand hygiene
compliance
1. (IA) Recommend
A. No comment
B. (IC) Recommend
C. (IB) Do not reuse the same
gloves (or wash them
between uses) with multiple
patients
D. (II) Recommend
A. (IA) Prohibited for high-risk
patients (e.g., in intensive
care unit or operating room)
B. (II) Recommend
C. Unresolved issue
(IA) Recommend
A. (IB) Recommend
B. (IC) Recommend
C. (IB) If re-use is necessary,
re¬process gloves adequately
between patients
D. (II) Recommend
A. (IA) Prohibited for all direct
patient contact in all settings
B. (II) Recommend
C. No comment
Provide alternatives for HCWs
with allergic or adverse reactions
to product
Emphasizes use of hand hygiene
after gloves are removed
Glove reuse may be necessary in
some areas. Recommends
implementing a glove
reprocessing method to maintain
glove integrity while adequately
cleaning gloves
Prohibition of artificial nails
expanded (see III.E above)
Recommendation CDC Guideline* WHO Guideline* Key Points of WHO Guideline
V. Use of gloves
VI. Other aspects of hand hygiene (nonsurgical)
Outcome Measures and Performance Indicators
i-128_HH_ptr.qxp 12/4/09 1:47 PM Page 10
11
Hand Hygiene Guidelines: The Foundation for Measurement
Appendix 1-1. (continued)
1. Direct observation with
HCW performance
feedback; calculate
number of hand hygiene
episodes performed per
number of opportunities
2. Indirect monitoring
a. Monitor volume of
product used for hand
hygiene
b. Other monitoring
c. Electronic monitoring
d. Monitor compliance
with facility policies
regarding jewelry, nail
polish, and artificial
nails
1. Recommend
a. Calculate volume used
per 1,000 patient days.
b. No comment
c. No comment
d. Recommend
nonspecific monitoring
1. Recommend
a. Estimate volume used
based on nursing
activities
b. Count used paper
towels
c. Monitor use of sinks,
hand hygiene product
or paper towels
electronically
d. Monitor compliance by
direct and indirect
observation, self-
assessment, and patient
assessment
Estimate volume instead of
calculating it
Alternative monitoring
Alternative monitoring
Specific measures to monitor
compliance
Recommendation CDC Guideline* WHO Guideline* Key Points of WHO Guideline
Source: © 2007, Joint Commission Resources. Written by Clare F. Pegues, R.N., M.P.H., P.H.N. Edited by Barbara M. Soule, R.N.,
practice leader, Infection Prevention and Control.
* Guideline Categories
The CDC and WHO categorize recommendations on the basis of existing scientific research, theoretical rationale, applicability, and
economic impact. The WHO also includes expert consensus in their categorization.
Category IA: Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or
epidemiologic studies.
Category IB: Strongly recommended for implementation and strongly supported by certain experimental, clinical, or epidemiologic
studies and strong theoretical rationale.
Category IC: Required for implementation, as mandated by federal and/or state regulation or standard.
Category II: Suggested for implementation and supported by suggestive clinical or epidemiological studies or a theoretical rationale
[or per the WHO a consensus by a panel of experts].
Measuring hand hygiene practice can be complex, and there
is little consensus on the most effective measurement
methods. This chapter addresses three important questions
that will help you decide which measurement methods are
best suited to your organization’s purposes:
• Why do you want to measure hand hygiene practices,
and what are your organization’s goals?
• What elements of hand hygiene do you want to
measure?
• How do you want to measure hand hygiene?
WHY DO YOU WANT TO MEASURE HAND
HYGIENE PRACTICES, AND WHAT ARE
YOUR ORGANIZATION’S GOALS?
Health care organizations measure hand hygiene practice as
part of an effort to prevent health care–associated infec-
tions and the transmission of microorganisms.
1–4
The
measurement strategy, however, depends on specific orga-
nizational goals. Organization goals might include the
following:
• To assess the performance of individual staff members
and educate them by intervening in real time
• To periodically assess the organization’s level and
quality of practice for regulatory or accreditation
purposes
• To measure the organization’s performance within
high-risk patient populations or units
• To assess the impact of a quality improvement
intervention to increase adherence to hand hygiene
guidelines
• To compare the health care organization’s performance
to that of others
• To investigate an infection outbreak
• To conduct a research project
• To improve patient and family perception of quality
of care
Additional questions to consider include:
• How do we want to display and use the results?
• What reports will we need to generate?
• To whom will we report the results?
• Do we want to be able to generalize the measurement
results to the entire organization?
• Do we plan to track our rates over time?
• Do we want to stratify our results (by risk, type of
provider, time of day or shift, or unit/department)?
After your goals have been identified, your organization
will be prepared to address the next question: What ele-
ments of hand hygiene do you want to measure?
WHAT ELEMENTS OF HAND HYGIENE DO
YOU WANT TO MEASURE?
Some of the most common elements of measurement asso-
ciated with hand hygiene include the following:
• Components of the observed hand hygiene action,
such as the following:
— Type of supplies and products used (including
running water, liquid soap, alcohol-based hand
rub, paper towels, and gloves)
13
chapter 2
DEVELOPING A STRATEGY
FOR MEASURING HAND HYGIENE
— The professional affiliation of the health care
worker (for example, R.N., M.D., allied health
professional, volunteer)
— The thoroughness of cleansing (for example,
whether all hand surfaces are covered, whether the
proper amount of the product is used, whether
hands are cleansed for the recommended amount
of time)
— Whether hand hygiene is performed after removal
of gloves
• Indications, such as the following:
— Before patient contact
— Before an aseptic procedure
— After body fluid exposure risk
— After patient contact
— After contact with patient surroundings
• Structural considerations, such as the following:
— Product availability
— Product accessibility
— Whether dispensers and sinks are in working
order
— Placement of dispensers
• Product use, such as the following:
— Aggregated volume, quantity, or count
— Individual counts of usage
— Name or discipline of individual health care
workers using the product
• Adherence to policies, such as those regarding nail
length, use of artificial nails or nail extenders, and the
wearing of jewelry
• Staff knowledge about key elements of hand hygiene
practice
• Staff competence, such as use of appropriate
technique when cleansing hands
• Perceptions and attitudes of health care workers
regarding hand hygiene, as well as the perceptions and
attitudes of others, including patients and families
• Satisfaction with hand hygiene practices, including
the following:
— Patient/family satisfaction with staff performance
— Staff satisfaction with products and their
availability or placement
Appendix 2-1 is a table that shows these components
and which of the three measurement methods may be suit-
able for each.
When you have determined why and what you want to
measure, you need to select a measurement method, or a
combination of methods, that will meet your measurement
needs.
HOW DO YOU WANT TO MEASURE HAND
HYGIENE?
The three most commonly used methods for measuring
hand hygiene are observation, product measurement, and
surveys. Observation of health care workers involves
directly watching hand hygiene behavior and allows you to
proactively record the number of hand hygiene indica-
tions, opportunities, and actions. Observation of the
physical environment is useful for assessing structural con-
siderations. With product measurement, you indirectly
assess hand hygiene practice by calculating how much
liquid soap, alcohol-based hand rub, and paper towels are
used in a given area of the organization per patient day;
through the electronic monitoring of sinks and alcohol-
based hand rub dispensers
5
; or by automated counting
devices. Surveys can be used to gather information on
health care worker perceptions, attitudes, and practices
related to hand hygiene, as well as patients’ and families’
attitudes and perceptions related to the hand hygiene
practices of health care workers. Surveys can be adminis-
tered in person, over the telephone, electronically, or on
paper to health care workers, patients, and family
members.
Observation, product measurement, and surveys are
discussed in detail in Chapters 3, 4, and 5, respectively.
Appendix 2-2 provides an overview of the strengths and
weaknesses of each method. Knowing the strengths and
weaknesses of each measurement method, and how they
relate to your goals, will help you decide how to measure
hand hygiene practice. It is also important to consider what
your organization can afford in terms of staffing, cost, data
collection, analysis, and reporting before choosing a
method.
14
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
USING MULTIPLE METHODS TO MEASURE
HAND HYGIENE
It is often useful to implement more than one measurement
method at the same time. Using multiple measurement
approaches makes it possible to validate your results.
Because all measurement methodologies have weaknesses,
the level of confidence in your findings increases if you
obtain similar results when using different approaches.
Researchers call this triangulation, or the use of more than
one approach to study the same phenomenon.
6
Another advantage to approaching measurement from
multiple perspectives is that it can provide more and differ-
ent information than can be extracted from any single
method. For example, assessing both structural capacity
(that is, the availability of products and the proper func-
tioning of sinks and dispensers) and staff knowledge of
hand hygiene guidelines and reasons for noncompliance,
revealed through focus groups, allows you to better under-
stand your facility and staff and target your interventions.
Many studies have measured the effectiveness of an
improvement intervention by both observing care and
measuring product. Gould pointed out that questions
about the validity of direct observation can be overcome by
using additional, unobtrusive methods of data collection to
corroborate or refute findings.
3
These include using moni-
toring devices, measuring liquid soap or alcohol-based hand
rub, and tracking the rates of hospital-acquired infection.
Text box 2-1 describes how a few organizations have
used multiple methods to measure hand hygiene.
15
Developing a Strategy for Measuring Hand Hygiene
Text Box 2-1.
Using Multiple Methods to Measure Hand Hygiene
Infection Prevention and Control staff at Spartanburg Regional
Healthcare System in Spartanburg, South Carolina, use three
approaches to monitor their organization’s hand hygiene
practices:
• Monitoring hand hygiene practices of staff via observations
done by the following:
— Trained observers as part of the medical center’s “Nurse
Pride” program. These nurses observe health care
workers at the patient bedside during routine care, so
they see a cross-section of disciplines in the course of
their observations.
— Observation by the surveillance technician from the
Infection Prevention and Control department.
• Assessing patient satisfaction with staff hand hygiene
practices on a regular basis as part of an organizationwide
satisfaction survey. Initially the data from the satisfaction
survey indicated much lower adherence to hand hygiene
guidelines than the observational data. When Infection
Prevention and Control staff realized that patients did not
always see staff performing hand hygiene, they began
teaching staff to tell patients what they were doing and
why when they wash or use alcohol-based hand rub. Once
they made this change, data from the surveys began to
align more closely with observational data.
• Monitoring and trending the use of soap and alcohol-based
hand rub over time. Hospital staff measured the volume of
products purchased from vendors in fiscal years 2006 and
2007. They noticed an increase in the amount of wall-
mounted alcohol-based hand rub and pocket-size
alcohol-based hand rub purchased. This increase was
accompanied by observed improvements in staff hand
hygiene practices, including increased use of alcohol-based
hand rub.
The infection preventionist at Greenville Hospital System in
Greenville, South Carolina, uses multiple methods to track
staff hand hygiene activity. This multitiered system includes
the following:
• Direct observation by frontline health care workers and
others trained by the infection preventionist, including
nurses, respiratory therapists, physical therapists, and
security staff.
• Gathering of information about patients’ perceptions of
health care worker hand hygiene practices, using a patient
satisfaction survey. The preventionist sends this survey to a
random sample of inpatients and emergency department
patients.
• Monitoring of hand hygiene product usage systemwide,
with ounces of products used per 100 adjusted patient days
routinely reported. This measurement showed a statistically
KEY POINTS, CHAPTER 2
• Before you select a measurement method,
determine the answers to these key questions:
— Why do you want to measure hand
hygiene practices, and what are your
organization’s goals?
— What elements of hand hygiene do you
want to measure?
— How do you want to measure hand
hygiene?
• The three most commonly used methods to
measure hand hygiene are observation,
product measurement, and surveys.
• It is often a good idea to use more than one
method to measure hand hygiene at the same
time as this approach can do the following:
— Help to validate the results
— Uncover additional information that can
be used to identify areas in need of
improvement and target interventions
REFERENCES
1. Boyce J.M., Pittet D.: Guideline for Hand Hygiene In Health-
Care Settings: Recommendations of the Healthcare Infection
Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect
Control Hosp Epidemiol 23(Suppl.):S3–S40, Dec. 2002.
2. World Health Organization (WHO): WHO Guidelines on Hand
Hygiene in Health Care (Advanced Draft): A Summary. Geneva,
Switzerland: WHO, 2006.
3. Gould D.J., et al.: Measuring handwashing performance in health
service audits and research studies. J Hosp Infect 66:109–115, Jun.
2007.
4. Haas J.P., Larson E.L.: Measurement of compliance with hand
hygiene. J Hosp Infect 66:6–14, May 2007.
5. Bittner M.J., Rich E.C.: Surveillance of handwashing episodes in
adult intensive-care units by measuring an index of soap and paper
towel consumption. Clinical Performance and Quality Health Care
4:179–182, 1998.
6. Thurmond V.A.: The point of triangulation. J Nurs Scholarsh
33(3):253–258, 2001.
16
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Text Box 2-1. (continued)
significant increase in the use of both hand soap and
alcohol-based hand rub between 2006 and 2007.
Eastern Maine Medical Center in Bangor, Maine, also
considers hand hygiene adherence from several vantage points:
• Direct observation of staff and medical students by health
care workers trained by the infection preventionist.
• A brief patient survey, first conducted in the summer of
2007, repeated in 2008. Student volunteers who visited
patients asked the following questions:
— Has anybody talked to you about hand hygiene?
— Do you know where the alcohol gel is?
— Are you seeing staff clean their hands with soap and
water or gel before taking care of you?
— Do you feel comfortable asking your health care
providers if they have washed their hands?
— Would you like a small bottle of alcohol hand gel?
• Housekeeping staff members collect information on the
use of soap and alcohol-based hand rub. Each housekeeper
uses a check sheet to document how many empty
containers of soap and alcohol-based hand rub he or she
replaces each shift. The supervisor sends the total amount
of product used per unit per week to the hospital’s
infection control data coordinator, who calculates monthly
data points using the number of milliliters of product used
per unit, divided by the number of bed days for the same
time frame for each unit.
17
Developing a Strategy for Measuring Hand Hygiene
Appendix 2-1.
Components of Hand Hygiene Measurable Within the Three Major Methods
Component Observe Measure Product
1
Survey
1
Action occurred
• Type of product, agent, and supply used X X
• Professional background/discipline of health care worker (HCW)
cleansing hands X
• Thoroughness of cleansing X
• Appropriate use of gloves X X
Opportunity or indication
• Single or multiple specific indications for hand hygiene X
• Risk of indication X
Structural considerations
• Product available X X
• Product accessible X X
• Dispenser/sink works X X
Product use
• Individual or aggregated volume or quantity X
• Individual or aggregated counts of usage X
• Name/discipline of individual HCW using the product X
2
Nail length, artificial nails, jewelry, etc. (adherence to policy) X
Staff knowledge X
Staff competence X
Perception of health care worker behavior
• Self-perception X
• Perception of other health care workers X
Satisfaction with hand hygiene
Patient or family satisfaction with staff performance X
Staff satisfaction with availability of products X
1. Should generally be considered indirect or proxy measures related to the occurrence of hand hygiene.
2. Some electronic systems identify health care workers.
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 2-2.
Overview of Approaches to Measuring Adherence to Hand Hygiene Guidelines
Brief
Description
Strengths
Limitations
Observation
People observe hand hygiene
behavior and record the number of
hand hygiene episodes in relation to
recommended practices.
Can pinpoint the hand hygiene
behavior of individuals.
1,2
Can assess hand hygiene technique.
1
Most reliable method for assessing
adherence rates.
2
Awareness of observation can
influence staff behavior.
1,3
Labor intensive and costly.
1,2
Requires training.
1–3
Captures only a sample of all hand
hygiene opportunities.
1
Can compromise patient privacy.
1,3
Product Measurement
Measuring the amounts of liquid
soap, alcohol-based hand rub
(ABHR), paper towels, and gloves
used in a particular area over a
specified period of time.
Allows efficient monitoring of hand
hygiene per patient day over time in
a given unit.
1
Is not subject to selection or recall
bias.
1
Is less time-consuming and less
costly than other methods.
2
Does not reveal who is performing
hand hygiene.
1
Does not assess technique.
1,3
Does not capture hand hygiene
opportunities.
1,3
Cannot account for spillage, use of
product for purposes other than
hand hygiene, and “borrowing”
between wards.
3
Can be affected by a product use by
patients and families.
1
Can be difficult to correlate with
observation.
2
Validity has not been
well-estabished.
2
Surveys
Surveying health care workers
about their own hand hygiene
practices, knowledge, attitudes,
and product satisfaction.
Surveying patients and families
about their attitudes and
perceptions of the hand
hygiene practices of health care
workers.
Inexpensive.
1
Not resource intensive.
2
Can provide some information
on compliance.
2
Focuses health care workers’
attention on their own hand
hygiene practices.
1
Inadequate reliability or validity
for self-respect of adherence.
1,2,4
Health care workers tend to
overestimate compliance.
2
Validity depends on the
quality of the survey’s
development and testing.
1. Haas J.P., Larson E.L.: Measurement of compliance with hand hygiene. J Hosp Infect 66:6–14, May 2007.
2. World Health Organization (WHO): WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary. Geneva, Switzerland: WHO, 2006.
3. Gould D.J., et al.: Measuring handwashing performance in health service audits and research studies. J Hosp Infect 66:109–115, 2007.
4. Harrington L., et al.: Reliability and validity of hand hygiene measures. J Healthc Qual 29(4):20–29, 2007.
18
The observation method involves directly watching hand
hygiene behavior and allows you to proactively record hand
hygiene opportunities (based on the indications in hand
hygiene guidelines) and the action of hand hygiene.
According to the World Health Organization (WHO)
guidelines, observation is the “gold standard” for measuring
hand hygiene adherence. It is the only way to directly
measure health care workers’ adherence to hand hygiene
guidelines.
1
As described in Appendix 2-1, observers can
choose to assess various aspects of hand hygiene, such as the
quality and thoroughness of hand hygiene, the accessibility
and use of products and gloves, the discipline of the health
care worker performing hand hygiene, and adherence with
policies regarding jewelry and nail length. Importantly,
observation can also create an opportunity to provide health
care workers with timely feedback.
Observation is also commonly used to assess structural
considerations in the environment. For example, it can be
used to assess bed space to determine the percentage of
clean gloves in appropriate sizes, dispensers for liquid soap
or alcohol-based hand rub (either wall mounted or free-
standing), and whether dispensers are functioning and
dispense an appropriate amount of the product.
2
STRENGTHS AND LIMITATIONS OF THE
OBSERVATION METHOD
Each of the measurement methods covered in this mono-
graph has strengths and limitations that you should
consider as you develop your measurement goals and
consider which method or methods will work best for
you.
The strengths of an observation method include its
ability to do the following:
• Count both opportunities for hand hygiene and the
action of hand hygiene.
• Determine who practiced hand hygiene, verify when
they practiced it, and monitor the quality of their
hand hygiene.
2,3
• Observe the wearing of artificial nails, nail extenders,
and jewelry.
2,3
• Provide quantitative and qualitative information about
when and why failures in hand hygiene occur.
• Distinguish between hand hygiene practiced by
different types of health care workers and patients or
family members.
Limitations of an observation method include the fol-
lowing:
• It may be labor intensive and costly.
1,3
• It requires uniformity in the selection and training of
observers and in the recording of data.
1,3,4
• It can change the behavior of staff members if they are
aware that they are being observed.
3,4
• It captures only a small sample of all opportunities for
performing hand hygiene.
3
• It can compromise patient privacy.
3,4
19
chapter 3
OBSERVING ADHERENCE TO
HAND HYGIENE GUIDELINES
COMPONENTS OF THE
MEASUREMENT METHOD
Selecting Which Opportunities to Measure
Based on your measurement goals, you need to determine
which opportunities (that is, the points in time within a
care process when hand hygiene should occur, as specified
by guideline indications) and actions (performing hand
hygiene in response to an opportunity) need to be observed.
The WHO recommends using the five opportunities
described in Figure 1-1 in Chapter 1. As you evaluate your
options, you should consider the following issues that can
influence hand hygiene adherence rates:
• It is important to recognize that the adherence rate
you calculate is dependent on the opportunities you
choose to observe. Several studies have shown how
rates of hand hygiene adherence vary, based on which
hand hygiene opportunities are measured (see
Appendix 3-1). For example, hand hygiene adherence
before patient care is usually worse than hand hygiene
adherence after patient care.
• Hand hygiene opportunities vary greatly based on
patient mix. From unit to unit, day to day, and
clinician to clinician, the frequency of hand hygiene
opportunities varies, depending on the nature of the
interaction between the health care worker and the
patient and health care workers’ perceptions of their
own risk.
5
Several studies have looked at variation in
adherence rates based on the intensity of patient care
and the frequency of patient contact (see Appendix 3-
2).
• High intensity of patient care has been associated with
lower hand hygiene adherence in a multivariate
analysis.
6–9
The intensity of patient care—that is, the
activity index—is the estimated or expected number of
hand hygiene opportunities that occur per hour. In
addition, in many studies, higher patient workload—
that is, a greater number of hand hygiene opportunities
based on higher patient-to-staff ratios—has been
associated with poorer compliance (see Appendix 3-2).
It is important for the actions being measured to be
appropriately related to the opportunities you choose to
observe. “The action is considered necessary provided it
corresponds to at least one indication.”
14(p. 8)
Therefore,
actions that occur in the absence of the specific indications
or opportunities being measured should not be included in
the numerator of a rate.
Finally, in order to be useful, your observation must be
conducted in a standardized and consistent manner. If your
goal is to track improvement in hand hygiene adherence
over time, or to compare the performance of a specific unit
or facility against the performance of others, then the
approaches used to measure and calculate the adherence
rate must be identical. Comparisons that are based on non-
standardized measurement can lead to faulty conclusions
and bad decisions.
Deciding What Aspects to Observe
A first step in planning to observe the hand hygiene per-
formance of health care workers is to decide which aspects
of hand hygiene you want to observe and measure.
Observation allows you to determine which hand hygiene
products are used, the thoroughness of cleansing, the use of
gloves, and whether staff are performing hand hygiene
whenever there is an opportunity to do so. Observation also
allows you to determine whether the product used is appro-
priate for the risk of transmission (for example, not using
alcohol-based hand rub when there is an outbreak of
Clostridium difficile).
Type of Product or Agent Used
You can observe whether health care workers use soap and
water or alcohol-based hand rub in gel, foam, or liquid form
to clean their hands. Observing the type of products used
may help you to identify health care workers’ preferences or
changes in preferences following a change in products or in
the availability of products (such as adding more alcohol-
based hand rub dispensers in patient rooms).
Thoroughness of Cleansing
Observing the thoroughness of hand cleansing includes the
following:
• Observing whether all surfaces of the hands and
fingers are covered
20
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
• Observing whether the proper amount of product is
used
• Observing whether hand rubbing occurs for the
proper amount of time (that is, when washing hands
with soap and water, the Centers for Disease Control
and Prevention guidelines recommend rubbing hands
together for at least 15 seconds
10
; when cleansing
hands with alcohol-based hand rub, guidelines
recommend rubbing hands together until the hands
are dry)
When health care workers use soap and water to clean
their hands, you can observe whether they dry their hands
using clean towels, as guidelines recommend. When they do
not have access to automatic sinks, you can observe whether
they turn off the faucets with a paper towel.
Studies have shown that health care workers often
perform hand hygiene for very short periods of time and
often fail to cover all surfaces of their hands and fingers.
10,11
To increase adherence to and awareness of hand hygiene
guidelines, some organizations have incorporated hand
hygiene performance into annual competency reviews for
staff.
More information on assessing the thoroughness of
hand hygiene is available in Chapter 6.
Glove Use
In addition to technique, guidelines point out that health
care workers must use gloves properly, as gloves can become
contaminated during care.
1,10
Aspects of glove use that can
be observed include the following:
• Gloves are worn when indicated (that is, when contact
with blood or other potentially infectious material is
anticipated or when contact with excretions,
secretions, mucous membranes, and non-intact skin
could occur).
• Gloves are changed when indicated (that is, gloves are
removed after caring for a patient or when moving
from a contaminated body site to a clean body site).
• Gloves are removed properly (so as not to contaminate
hands in the process of removal).
Glove use does not take the place of hand hygiene.
1,10
The Institute for Healthcare Improvement (IHI) recom-
mends assessing staff competency with hand hygiene
technique and glove use; the IHI’s How-to Guide: Improving
Hand Hygiene recommends that 10 clinical staff be ran-
domly selected from diverse disciplines each month (or at
an interval specified by organization policy) so they can be
observed to see whether they perform the three key hand
hygiene procedures correctly: hand washing, application of
alcohol-based hand rub, and use of gloves, including remov-
ing them so as not to contaminate hands in the process.
2
While this step can be time-consuming, it allows for direct
evaluation of staff and the opportunity to provide immedi-
ate feedback. It also provides the opportunity to ensure that
staff are not wearing artificial nails or extenders and that
they have trimmed nails. This process would also work well
in a staff “competency day” setting, where staff have dedi-
cated time to perform various procedures or complete
written tests to show their proficiencies. (For more informa-
tion, see Chapter 6.)
Determining Who to Observe
You can collect data during hand hygiene observations of
health care workers according to their discipline:
• Nurses, nursing assistants, orderlies, physicians,
medical residents, pharmacists, and therapists
(pulmonary, physical, occupational, and speech
therapists)
• Technicians/technologists (lab, radiology, EKG/EEG,
pharmacy)
• Nonclinical staff (administrative assistants, office staff,
unit clerks)
• Environmental staff (engineering, maintenance,
housekeeping)
• Pastoral care, social workers, discharge planners
• Food service staff
• Transporters
• Vendors
• Students, visitors, patient sitters, parents/guardians
Collecting hand hygiene data by staff discipline can
help you target and tailor interventions aimed at improving
21
Observing Adherence to Hand Hygiene Guidelines
hand hygiene practices. Several researchers have studied
adherence to hand hygiene by health care worker discipline.
Much of this literature shows higher adherence among
nurses than physicians and among female physicians than
male physicians, though other researchers have had differ-
ent findings (see Appendix 3-3).
Hand hygiene observation can also be directed toward
patients. Poor patient hand hygiene can contribute to
patient infections. To determine whether patient hand
hygiene is an underlying problem, you need to observe their
hand hygiene behavior. One hospital that identified an
infection concern believed to be related to patient hand
hygiene is described in Text Box 3-1.
Conducting Observations
Once you have determined the opportunities and actions
you will observe, you need to develop a plan for conducting
your observations.
Dealing with “Double Counting” Opportunities
It is essential that observers be able to determine what qual-
ifies (that is, what should be counted) as an opportunity or
an action. Opportunities and actions must be operationally
defined to ensure that an accurate tally can be kept.
In addition, the act of “double-counting” can present a
conundrum. This issue arises when a health care worker
appropriately performs hand hygiene after contact with one
patient and then goes directly to another patient to provide
care without again performing hand hygiene. Technically,
the health care worker has not performed hand hygiene
“before” contact with the second patient, but he or she has
practiced adequate infection control. Alternatively, if the
health care worker leaves the room or moves between two
patients in the same room without performing hand
hygiene after the first encounter—but does perform hand
hygiene before the second encounter—the guideline has
been followed but would not be counted as such.
12,13
If your
hand hygiene observation protocol measures hand hygiene
both before and after each patient contact, it is worth con-
sidering how this would be addressed as the observers
collect their data. Some programs that have addressed this
issue are described in Text Box 3-2.
Determining When and How Frequently to Observe
Deciding when and how frequently to observe health care
workers conducting hand hygiene depends on your reasons
for monitoring and the resources you have at your disposal.
For example, the frequency of monitoring for quality
improvement may be different from the frequency of mon-
itoring for regulatory purposes. Some organizations
perform observations daily, while others conduct them
weekly, monthly, or quarterly. If you want to monitor per-
formance over time, be sure your measurement periods
allow for long-term trending of data. If you are concerned
22
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Text Box 3-1.
Observing Patients
Shriners Hospital for Children in Chicago is a short-term, 60-
bed pediatric facility that provides medical, surgical, and
rehabilitative care for children with orthopedic conditions. The
infection preventionist noticed an increase in patients with
urinary tract infections at the end of 2006. Many of the
hospital’s patients have neurogenic bladders and require
intermittent self-catheterization. At the same time, the spinal
cord injury coordinator wanted to trial a new “no touch” type
of catheter. Their efforts were combined and resulted in a
urinary tract initiative that included a survey asking patients
and caregivers how they performed catheterizations at home.
They learned that many did not clean their hands before
performing the procedure. The two nurses involved their
nursing staff in the initiative, and staff observed patients and
caregivers performing the procedure to assess their technique.
They taught patients proper hand hygiene techniques, stressed
the importance of performing hand hygiene before every
procedure, and provided each patient with individual bottles of
alcohol-based hand rub. The initiative was successful in
decreasing the incidence of urinary tract infections in this
patient population.
about an outbreak in a particular unit or department, the
frequency of your observations will probably increase for a
period of time but then revert back to your usual monitor-
ing when the outbreak has resolved. Consider your
resources as you make decisions about observing (time for
collecting, collating, and reporting).
It is important to collect hand hygiene observations
during a variety of weekday, weekend, and holiday shifts in
order to get a complete picture of hand hygiene practices.
Experts recommended planning observation activities
across 24 hours to get a complete picture.
4
This can be done
roughly in proportion to the expected number of opportu-
nities for hand hygiene across shifts. For example, you may
need fewer observations on nights and weekends because
there are fewer opportunities for hand hygiene. One study
showed that adherence is worst during weekdays and morn-
ings, when the activities requiring hand hygiene are more
frequent.
6
Determining How Many Observations Are Needed
The WHO Manual for Observers recommends observing a
minimum of 200 opportunities during each measurement
period in each department or ward to allow for meaningful
comparison before and after hand hygiene improvement
interventions.
14
This number is suggested to ensure that the
number of opportunities observed is sufficient to draw valid
conclusions within groups. However, it should be noted
that 200 is not an exact or required number for all purposes.
You might want to consult a statistician to determine
sample size calculations specific to your needs. The main
point is that small sample sizes tend to yield findings that
are not as reliable as larger samples.
Researchers have pointed out that the number of obser-
vations conducted is often much too low when compared
with the number of opportunities for hand hygiene. This is
one of the major limitations of using observation to
measure adherence. Van de Mortel et al. explained it this
way: If one conservatively estimates 10 opportunities for
hand hygiene per patient per hour in the intensive care unit,
and multiplies that by the number of patients and the
number of hours per day, one can estimate the number of
opportunities per day. Then one can compare that to the
proportion of opportunities actually observed.
15
For
example, 12 patients times 10 opportunities per patient per
hour times 24 hours per day patients yields 2,880 opportu-
nities per day, or almost 86,500 opportunities per month. If
for your routine monitoring each month you observe 100
opportunities in the intensive care unit, you are only meas-
uring one-tenth of 1% (0.12%) of all opportunities in a
given month. Imagine how small the percentage would be
if you included in the calculation the total number of
patients in your health care organization rather than just
intensive care patients.
23
Observing Adherence to Hand Hygiene Guidelines
Text Box 3-2.
Avoiding Double Counting
The Ontario, Canada, “Just Clean Your Hands” program instructs
observers that when a health care worker moves directly from one
patient to another, this should be recorded as two indications
within one opportunity (e.g. after patient contact and before
patient contact). (See http://www.justcleanyourhands.ca/
program_overview.php.)
Researchers in the United Kingdom have included directions
on how to avoid double counting in their instructions on
using their observation tool, specifying that “hand hygiene
opportunities should not be double-counted. If a healthcare
worker is observed moving directly from one hand hygiene
opportunity to another, without any intervening opportunities,
this should be classified as one ‘after’ opportunity and not as
an ‘after’ and as a ‘before’ opportunity.” (See Hand Hygiene
Observation Tool (HHOT) and instructions available at:
http://www.idrn.org/nosec.php; shorter summary version at
http://www.npsa.nhs.uk/cleanyourhands/in-hospitals.)
Determining Where to Measure: Structuring and
Scheduling Your Observations
Deciding where to measure depends on your reason for
measurement. The priority settings for observation are
often based on surveillance and prevalence data, which
can change based on infection rates and outbreaks. You
can learn a great deal about how to design your own
approach to observing hand hygiene by learning how
previous observation studies have been designed, includ-
ing the details of methodology, how observation periods
were selected, who did the observing, and how observers
were trained. Several of these studies are described in
Appendix 3-4.
For organizationwide monitoring, it can be helpful to
have a structured schedule for selecting settings. Text Box 3-
3 contains a hypothetical sampling framework for selecting
units and time frames for observation.
Selecting a Sample of Health Care Workers or Patients
to Observe
The purpose of sampling is to be able to take a limited
number of observations and be reasonably confident that
24
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Text Box 3-3.
Sample Observation Schedule
Janet, an infection preventionist, wants to observe staff hand
hygiene behavior four times a year in each of the nursing units.
For each unit, she wants to conduct one-half of the
observations between 7 A.M. and 7 P.M., one-fourth between 7
P.M. and 7 A.M., and one-fourth on weekends. She has trained
three staff members in how to conduct the observations, based
on the Center for Disease Control and Prevention’s 2002
guidelines and indications for hand hygiene. Each observer
watches hand hygiene opportunities on each of the assigned
units every month, using a form Janet adapted from the
WHO’s World Alliance for Patient Safety hand hygiene data
collection form. The observer records each hand hygiene
opportunity for each staff member observed and then records
whether hand hygiene was performed. Janet has assigned units
for the current year according to the following schedule:
Observer 1: Sue
Observer 2: Nancy
Observer 3: Chris
Observer 4: Janet
Janet will analyze observations according to the discipline
of the caregiver and the shift/day of week each was observed.
they represent the larger population of interest. An impor-
tant decision to consider is whether a sample needs to be
representative of the larger population. There are a number
of approaches to selecting a sample of locations and/or
health care workers, including random sampling, conven-
ience sampling, and quota sampling. Additional
information on sampling strategies is provided in Appendix
3-5.
Determining Who Will Conduct Observations
Infection Preventionists
In many organizations, infection preventionists observe
hand hygiene and collect information about performance.
Using infection preventionists as observers has advantages
and disadvantages:
Advantages:
• Infection preventionists have knowledge of hand
hygiene guidelines.
• They can intervene and teach on the spot to correct
unacceptable hand hygiene performance and may
require less training on guidelines than other
personnel.
• They can provide immediate feedback to staff for
good hand hygiene performance.
Disadvantages:
• Staff recognize infection preventionists, which makes
it difficult for them to observe without health care
workers’ awareness. Staff awareness can result in a
Hawthorne effect, where a individuals’ knowledge of
observation causes them to change their behavior and
makes it difficult to observe “true” hand hygiene
performance. The Hawthorne effect is described in
more detail later in this chapter.
• Having infection preventionists conduct observation
prevents ownership of unit staff in monitoring hand
hygiene.
Other Personnel
Instead of using infection preventionists, another approach
to data collection is to engage staff from across the facility
to perform observations. This can promote widespread
acceptance of, ownership of, and participation in activities
to improve hand hygiene. It can also be an eye-opening
experience for staff regarding the true level of hand hygiene
adherence. In addition, observer training should increase
staff knowledge of hand hygiene guidelines and heighten
their awareness that hand hygiene is an organizational
concern, not just something for which the infection preven-
tionist or quality improvement department is responsible.
However, it is sometimes not a good idea to use staff as
observers within their own departments because they might
be inclined to rate their coworkers better than outside
observers would, thus biasing the data.
3
Text Box 3-4 provides some examples of ways in which
infection preventionists have involved staff in their organi-
zations to observe hand hygiene performance.
Patients
In some organizations, patients are asked to provide infor-
mation on health care worker hand hygiene. (Using
patients as observers is not the same as using patients to
remind health care workers to perform hand hygiene,
which is a commonly used strategy for improvement; that
strategy is described in more detail in Chapter 9.) Using
patients as observers may be most effective in settings such
as ambulatory care, in which patients are relatively healthy
and where independent observers are rarely used. Keep in
mind that staff need to know they should perform hand
hygiene in front of a patient; the patient will not see hands
being cleansed if it is done outside a patient’s field of
vision.
It can be a challenging to include some patient popu-
lations, such as patients who are cognitively impaired,
critically ill, or unable to speak the common language. In
addition, patients can assess only basic indications, such as
hand hygiene performed before and after care. Nicol and
Watkins noted that health care workers who do not
perform hygiene upon leaving a patient room may do so
in another location prior to contact with another patient;
in such cases, failure to perform protocols to the letter may
not necessarily be the same as failure to perform hand
hygiene.
12
25
Observing Adherence to Hand Hygiene Guidelines
Text Box 3-5 describes how one organization imple-
mented a process of engaging patients as observers of staff
hand hygiene practices.
Overt Versus Covert Observation
Observations can be overt, with health care workers being
aware that they are being observed, or covert, with health
care workers either being unaware that they are being
observed or unaware that they are being observed as part of
hand hygiene monitoring. There are advantages and disad-
vantages to both overt and covert observation.
Overt observation allows for access to staff, immediate
feedback, and staff education. Overt observations can be
done by following, or “shadowing,” staff, or they can be less
26
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Text Box 3-4.
Engaging Staff to Observe Hand Hygiene
There are two hospitals in Asante Health System in Medford,
Oregon: the 365-bed Rogue Valley Medical Center and the
125-bed Three Rivers Community Hospital. From 2005 to
2007, these two organizations used “safety representatives” to
observe hand hygiene performance, following an initial one-on-
one orientation with the patient safety coordinator. At that
time, Rogue Valley Medical Center had 35 safety
representatives, and Three Rivers Community Hospital had 18.
Each organization held two to four group retraining sessions,
which encompassed various topics, including hand hygiene, at
the safety representatives’ periodic meetings. The representatives
conducted random covert observations on their own units or
departments, each observer submitting data on 20 to 40 health
care worker observations per quarter. They made an effort to
conduct some observations on night shifts and weekends.
Liberty Hospital in Liberty, Missouri, is a 245-bed community
hospital that has been monitoring hand hygiene since 2003.
Initially, the infection preventionist and light-duty personnel
observed the hand hygiene practices of health care workers in
various care settings. They decided, however, that the
observations did not adequately represent hand hygiene
practices hospitalwide, so they decided in 2004 to organize a
group of trained staff from approximately 20 different
departments or units to conduct observations during their
regular work hours. These individuals were named “The
Germinators.” Each Germinator was trained in recognizing
hand hygiene opportunities and how to use the data collection
tool. They were also trained to give feedback to staff on lapses
in hand hygiene technique and held practice sessions to make
them more comfortable giving both positive and negative
feedback. The Germinators noted the activity the health care
worker was involved in when hand hygiene was not
performed, which has provided valuable feedback to the
infection preventionist: She found early on that most staff
thought they should cleanse their hands only after patient
contact, not after contact with the patient’s environment.
Feedback such as this allowed the infection preventionist to
focus her hand hygiene education efforts during the hospital’s
annual education days. Each Germinator collects data on at
least 10 observations in his or her unit or department each
month; more than 800 observations are collected
organizationwide per quarter. This responsibility for
monitoring hand hygiene is considered in each Germinator’s
annual evaluation and merit increase.
Jewish Hospital in Cincinnati, Ohio, is a 200-bed suburban
teaching hospital. In their effort to evaluate staff hand hygiene
performance, the infection preventionists developed and began
to use a hand hygiene monitoring tool to record the
observations of trained patient safety leaders from
approximately 20 departments or units in late 2003. Each
patient safety leader conducts 15 to 20 observations per month.
If an observer sees a hand hygiene infraction, he or she informs
the person being observed immediately; if the observer is
uncomfortable providing this feedback, the observer informs
the department or unit manager, who provides feedback to the
staff member. The observers send their completed hand hygiene
monitoring forms to the chairperson of the patient safety
leaders, who forwards them to the infection preventionist. The
infection preventionist sends quarterly reports to the infection
control, patient safety, and environment of care committees, as
well as to each department manager. At these meetings,
committee members discuss recommendations for
improvement and develop improvement plans based on their
recommendations; committee meeting minutes document all
follow-up work. Hand hygiene monitoring is only one of the
safety-related activities for which patient safety leaders are
responsible; they also educate staff about a variety of aspects of
safety, act as role models, and conduct other safety audits.
obtrusive, with the observer maintaining some distance
from the staff. With overt observation, however, the
Hawthorne effect can occur. The Hawthorne effect refers to
the tendency of people who know they are being observed
in a research context to behave differently from the way
they would otherwise behave, thereby impacting the results
(also see Text Box 3-6).
16
There is ample evidence that the
Hawthorne effect will have an impact on data if staff are
aware that they are being observed. A number of studies
that have considered this impact are summarized in
Appendix 3-6. Some suggest that the Hawthorne effect can
be advantageous; the notion that “big brother is watching
you” should be promoted in a cost-effective way if it
achieves improved adherence and lower infection rates.
17
27
Observing Adherence to Hand Hygiene Guidelines
Text Box 3-5.
Patients as Observers of Staff Hand Hygiene
Tripler Army Medical Center in Honolulu, Hawaii, is a
231-bed teaching facility and the largest Army medical
treatment facility in the Pacific Basin. In January 2007,
Tripler’s hand hygiene initiative, named the Semmelweis
Project, began in a single hospital outpatient clinic. Because
most patients are seen behind closed doors and cannot be
observed by colleagues, the medical center decided to try using
patients to observe staff hand hygiene practices. The goal of
this project has been to enhance staff performance of hand
hygiene in front of patients before providing care. When
patients register at the clinic, they are given a 3 x 5 card that
reads on one side as follows:
Be Involved in Your Care!
• Using soap and water or alcohol rubs is one of the ways
that helps us to prevent the spread of germs.
• Please observe our health care provider to see if they wash
or use the alcohol rub before providing your care.
• Take an active part in your care by completing the reverse
side of this card and placing it in the receptacle in the
reception area.
The other side of the card is the observational tool, with
the name of the clinic and date, a place to select the type of
health care worker the patient will be seeing (physician, nurse,
or other) and a place to checkmark next to “yes” or “no” for
“performed hand hygiene.”
The participating clinic keeps track of the number of cards
it gives to patients. Patients complete the forms and place
them in the receptacle at the reception desk approximately
58% of the time. The infection preventionist collects the cards,
aggregates the data, provides monthly feedback to the clinic,
and produces a monthly report for the Performance
Improvement Council.
Tripler Army Medical Center Infection Control and Epidemiology
Program Manager Stephen Yamada and Guy Dickinson, Lead
Medical Support Assistant, Adult Medicine Clinic, demonstrate
how patients return their hand hygiene observation cards to the
receptacle.
The infection preventionist says this method serves five
purposes:
• It helps to educate patients about the importance of hand
hygiene.
• It empowers patients to be active participants in their care.
• It attempts to improve health care providers’ adherence to
hand hygiene guidelines.
• It fosters a culture within the medical center in which
routine hand hygiene becomes the norm.
• It helps to validate the data staff collect from internal
observations.
To date, Tripler has expanded this patient observation
method to an additional five clinics, with plans to add five
more.
Covert observation, such as using “secret shoppers,”
tends to minimize the Hawthorne effect but does not
provide an opportunity for immediate staff feedback.
Covert observation can also result in missed observations of
hand hygiene opportunities if the observer is stationary,
such as when he or she is sitting at a desk. In research
studies, covert observation can also have potentially nega-
tive ethical implications because staff are not being
informed of the observation or are given misleading infor-
mation about its purpose
4
; some believe the secret shopper
method of covert observation can create a lack of trust.
19
However, one organization that used secret shoppers for
covert observations found this to be a very useful approach
that had a positive impact on staff and their hand hygiene
adherence. This organization’s story is described in Text Box
3-7.
Privacy Considerations
It’s important to take patient and health care worker privacy
issues into account when planning and carrying out all
observations. The importance of privacy issues is recognized
in the following observer training materials:
• The WHO notes in its Manual for Observers the
importance of patient privacy. The manual states,
“Observation does not justify infringing the principle
of patient privacy. This means observers show discre-
tion regarding where they place themselves and their
movements.”
14(p. 25)
• Ontario’s hand hygiene program’s instructions for
observers state, “The observer must conduct observa-
tions openly, without interfering with the ongoing
work, and keep the identity of the healthcare
providers confidential.” There are no identifiers or
names recorded on their observer tool. (See
http://www.justcleanyourhands.ca.)
Using Technology in Observations
Observing staff members’ hand hygiene behavior using
technology such as video cameras is an unobtrusive way to
collect data. There is less selection bias with this method,
but bias is not completely eliminated; the range of cameras
can be limited, and it is possible that the cameras will not
“see” all dispensers. You can use cameras either randomly or
continuously, but purchasing and installing the equipment
can be expensive, and someone will need to review the
stored data and interpret and record what they see. In addi-
tion, cameras can interfere with the privacy of both staff
members and patients, and not all indications are recorded
by this technology.
3
A group of Japanese researchers studied the hand
hygiene practices of individuals entering the intensive care
unit at Osaka University by using continuous video camera
surveillance. Hospital policy requires all health care workers
and visitors to cleanse their hands before entering the inten-
28
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Text Box 3-6.
The Hawthorne Effect
The effects of observation on the activity being studied
were documented initially during productivity experiments
at the Hawthorne Western Electric Plant in Cicero, Illinois,
in the 1930s. The researchers noticed that, regardless of the
variable being manipulated, job performance improved
when workers were being observed.
18
Text Box 3-7.
Using Secret Shoppers in a Hospital
When The Methodist Hospital in Houston, Texas,
decided to monitor hand hygiene adherence among staff, it
elected to use observers who were not hospital staff but
outside consultants, infection prevention and control
experts hired by the hospital to observe staff hand hygiene
practices. These trained observers wore hospital badges and
otherwise looked like hospital staff, but their sole purpose
was to see whether staff cleansed their hands when they
should. They observed physicians, nurses, and ancillary staff
as they performed their normal activities, with two-thirds of
their observation on weekdays between the hours of 7 A.M.
and 7 P.M., and one-third on weekends and between the
hours of 7 P.M. and 7 A.M. The hospital began collecting
data this way in 2006, when leadership undertook a
comprehensive effort to improve quality and wanted to
avoid the bias that can result from using an organization’s
own staff.
20
.
sive care unit. Video cameras were mounted on the ceiling,
near two sets of sensor-regulated automatic doors and hand
hygiene stations at the intensive care unit’s only entrance.
An infrared alarm sensor was located on the ceiling, close to
the first automatic door, and a person passing under this
sensor triggered the video recorder to begin recording. The
researchers conducted the recordings for one week. Staff
and visitors were not aware of the study or the purpose of
the video cameras. There were 1,030 entries to the intensive
care unit during the observation period. While visitors per-
formed hand hygiene 94% of the time, intensive care unit
staff did so only 71% percent of the time and non-intensive
care unit staff did so only 74% of the time. The researchers
used this information to provide feedback to staff on the
importance of hand hygiene.
21
Standardizing Observation
The Importance of Observer Training and Assessing
Reliability
Infection preventionists have reported very different hand
hygiene rates for the same units, depending on the role and
training of the observer.
3
This influence can be minimized
by thorough training and a clear, consistent definition of
what to observe. Any observation includes an inherent
observer bias, which is the extent to which the observer
inaccurately identifies or measures a phenomenon.
Vandenbroucke et al. define bias as a systematic deviation of
a study’s result from a true value that is usually introduced
during the design or implementation of a study and cannot
be corrected after the fact.
22
Proper training can sometimes
require hours; training associated with major initiatives
such as the “Just Clean Your Hands” program in Ontario
(described further in Chapter 7), can take 4 to 6 hours.
In addition to training, it also helps to provide detailed
written instructions with the observation form. This ensures
that observers will have at hand all the information neces-
sary to conduct their observations in a standardized way and
thus maintain the reliability of the process. The following
are examples of observation tools submitted for the
Consensus Measurement in Hand Hygiene (CMHH)
project that include detailed instructions (see Appendix:
Examples of Measurement Tools):
• Ontario, Canada’s “Just Clean Your Hands”
observation tool
• Reedsburg Area Medical Center’s “Hand Hygiene
Observation Tool”
• U.K. researchers’ “Hand Hygiene Observation Tool”
(HHOT)
• The U.S. Department of Veterans Affairs “Hand
Hygiene/Glove Use Observational Tool”
• World Alliance for Patient Safety “Observation Form”
To determine whether training has been effective and
whether there is consistency in data collection, you should
also consider assessing reliability among observers, if more
than one observer will be collecting data. Reliability among
observers is often referred to as interrater reliability or inter-
observer reliability. After two or more observers observe and
document the same event, interrater reliability is deter-
mined by comparing the amount of agreement or
disagreement in their assessments or measurements.
23
One initiative that measured interrater reliability is
described in Text Box 3-8.
Documenting Your Methods
When reporting hand hygiene results, it is important to
completely describe the methodology used for data collec-
tion.
4
Reported details of the observation should include
interrater reliability if there is more than one data collector,
the vantage point of the data collectors, and attempts
undertaken to overcome the Hawthorne effect.
Determining How to Calculate Adherence Rates
Generally, when observation is used to measure hand
hygiene adherence, “the action is compared with the oppor-
tunity.”
14(p. 8)
The result is called the adherence rate, and it is
typically calculated as follows:
Total number of acts of hand hygiene when the opportunity existed
Total number of hand hygiene opportunities
Adherence rates can be calculated in a variety of ways.
Understanding the impact of using different rate calcula-
tions is important as you make decisions about how you
29
Observing Adherence to Hand Hygiene Guidelines
will interpret and use your observation data. There are three
primary calculation types, or measures:
• Item-by-item measures
• Composite measures
• All-or-none measures
A brief description of each is presented here; a more in-
depth review is available elsewhere.
25
Item-by-Item Measures
Item-by-item measures allow you to look at hand hygiene
adherence for opportunities related to a single indication.
When calculating this kind of rate, the denominator is the total
number of opportunities for a given indication. The numera-
tor is the total number of hand hygiene actions observed when
the opportunity is present. For example, if you observed hand
hygiene behavior using an approach that was consistent with
the WHO’s Five Moments for Hand Hygiene (see Chapter 1),
you would calculate item-by-item rates as follows:
# of observed hand hygiene actions before patient contact
# of hand hygiene opportunities observed before patient contact
and
# of observed hand hygiene actions before aseptic task
# of hand hygiene opportunities observed before aseptic task
and
# of observed hand hygiene actions after body fluid exposure risk
# of hand hygiene opportunities observed after body fluid exposure risk
and
# of observed hand hygiene actions after patient contact
# of hand hygiene opportunities observed after patient contact
and
# of observed hand hygiene actions after contact with patient surroundings
# of hand hygiene opportunities observed after contact with patient surroundings
30
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Text Box 3-8.
Interrater Reliability Testing
Researchers in the United Kingdom developed and tested
the reliability of an observation tool as part of a national
study of feedback effectiveness. They published their
detailed assessment in 2008.
24
To determine interobserver
agreement for individual hand hygiene opportunities and
subsequent hand hygiene behavior, two trained observers
watched identical hand hygiene opportunities in six two-
hour-long observation sessions. These observations took
place in an intensive care unit and an acute care ward at one
London hospital. The observers sat near each other in the
bed areas but not close enough to see each other’s data
collection forms. Each of the 298 observed opportunities
was recorded on a separate observation form. After each
opportunity was observed and recorded, the observers would
confer to determine whether they had observed and
documented the same opportunity. Raw agreement (percent)
and kappa (see the glossary in Appendix I-1 for more
information on kappa) were 77% and 0.68 for observed
hand hygiene behavior; 83% and 0.77 for hand hygiene
opportunities assessed; and 90% and 0.77 for the type of
health care worker observed.
The researchers also evaluated interobserver agreement for
overall hand hygiene adherence, with 4 trained observers
conducting 19 hours of observation (1,191 opportunities
observed). Working in pairs during 1-hour observation
periods, the observers sat near each other so they had the same
vantage point; each observer recorded multiple events on one
data collection form. At the end of the 1-hour period, each
observer calculated the overall assessment of health care
workers’ hand hygiene adherence. Overall agreement was good
(interclass correlation coefficient = 0.79).
In addition, study participants demonstrated that the tool
was sensitive to change. Researchers assessed this by having a
trained observer in an intensive care unit for 1 hour per day
over the course of several months, during which an outbreak
occurred and the emphasis on hand hygiene was increased.
The tool helped researchers to detect the increase in hand
hygiene adherence.
x 100
x 100
x 100
x 100
x 100
Composite Measures
A composite measure is a compilation of multiple indications
into a single adherence rate. You calculate this type of
measure by dividing the sum of observed actions (numerator)
by the sum of observed opportunities (denominator). It is
important to note that this type of calculation gives partial
credit for incomplete care or performance, as some caregivers
might have performed hand hygiene for some, but not all, of
the opportunities observed. So, if you observed hand hygiene
behavior, you would calculate a composite rate as follows:
{(# of observed hand hygiene actions before patient contact)
+
(# of observed hand hygiene actions before aseptic task)
+
(# of observed hand hygiene actions after body fluid exposure risk)
+
(# of observed hand hygiene actions after patient contact)
+
(# of observed hand hygiene actions after contact with patient surroundings)}
{(# of hand hygiene opportunities observed before patient contact)
+
(# of hand hygiene opportunities observed before aseptic task)
+
(# of hand hygiene opportunities observed after body fluid exposure risk)
+
(# of hand hygiene opportunities observed after patient contact)
+
(# of hand hygiene opportunities observed after contact with patient surroundings)}
X 100
All-or-None Measures
All-or-none measures calculate adherence rates by applying
the “all-or-none” rule at the patient level: Either all hand
hygiene opportunities are addressed by corresponding
actions or they are not. If a health care worker is expected
to perform hand hygiene at each opportunity within his or
her environment, the observer would note whether the
health care worker performed hand hygiene at all hand
hygiene opportunities within each patient encounter. If a
health care worker performed hand hygiene before patient
contact and after body fluid exposure risk, but not after
patient contact, the health care worker would be recorded as
not having performed hand hygiene appropriately. To calcu-
late an all-or-none adherence rate, use the following
formula:
# of patient encounters observed where hand hygiene was performed at
all opportunities (before patient contact, before aseptic task, after body fluid
exposure risk, after patient contact and after contact with patient surroundings)
# of patient encounters during which at least one opportunity was observed
This method of calculating hand hygiene adherence is
philosophically closer to reflecting the interests of
patients, where violation of a single aspect of hand hygiene
can result in cross-contamination and patient infection. It
also fosters a system perspective, with concern for the total
patient care episode, not isolated parts. This is the
approach that the IHI recommends in its How-to Guide:
Improving Hand Hygiene.
2
Hand hygiene adherence rates
are calculated as complete episodes of patient care—an all-
or-nothing adherence measurement; all aspects of hand
hygiene and glove use must be performed correctly during
a patient encounter. This raises the bar, recognizing that,
from the patient’s perspective, anything less than complete
adherence is unacceptable. Another benefit of the IHI tool
is that it permits direct calculation of rates on the data col-
lection form. However, it can be difficult and
time-consuming to observe complete patient contacts
from start to finish, especially when patient privacy issues
are considered.
The following is a simple example that illustrates how
calculating the rates differently affects the outcome.
Scenario: An infection preventionist observed 100 sep-
arate encounters between nurses and patients to determine
adherence to the guidelines. She found that hand hygiene
was performed before patient contact in 50 of 100 encoun-
ters, before aseptic task in 10 of 15 encounters, after body
fluid exposure risk in 30 of 32 encounters, after patient
contact in 60 of 100 encounters, and after contact with
patient surroundings in 10 of 45 encounters. Hand hygiene
31
Observing Adherence to Hand Hygiene Guidelines
x 100
x 100
was performed at all opportunities during 25 of the 100
total encounters.
Using the alternative methods for calculating rates, we
come up with the following percentages:
Item by item:
• 50/100 before patient contact opportunities = 50%
adherence rate
• 10/15 before aseptic task opportunities = 66.6%
adherence rate
• 30/32 after body fluid exposure risk opportunities =
93.8% adherence rate
• 60/100 after patient contact opportunities = 60%
adherence rate
• 10/45 after contact with patient surroundings
opportunities = 22.2% adherence rate
Composite:
• (50 + 10 + 30 + 60 + 10) actions / (100 + 15 + 32 +
100 + 45) total opportunities = 160 actions / 292
total opportunities = 54.8% composite adherence rate
All-or-none:
• 25 encounters where all eligible hand hygiene actions
were performed / 100 encounters = 25 / 100 = 25%
all-or-none adherence rate
Two organizations that submitted their measurement
method for evaluation as part of the CMHH project and
that use the all-or-none approach to calculating adherence
rates are described in Text Box 3-9.
KEY POINTS, CHAPTER 3
• Observation is the only way to directly
measure health care worker adherence to hand
hygiene guidelines.
• Adherence rates will vary depending on which
indications are measured, by whom, and in
which patient populations, as well as by the
method used for calculating rates.
• Spending time and effort in training data
collectors and selecting user-friendly forms
with clear instructions will greatly enhance
the accuracy and credibility of the
measurement results.
32
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Text Box 3-9.
Examples of All-or-None Calculation Method
Mayo Clinic in Rochester, Minnesota, comprises two large
inpatient hospitals with a combined 1,600 beds and a large
primary and subspecialty practice that have teaching programs
for medical students, nurses, and allied health professionals.
Their “Hand Hygiene and Glove Use Monitoring Form” was
developed initially as part of a research study and later
simplified and adapted for use in the IHI’s How-to Guide:
Improving Hand Hygiene.
2
The form captures the type of health
care worker, the nature of the contact (patient or environment
and whether hand hygiene was done before contact), and glove
usage (whether required, whether used, and whether hand
hygiene was done after gloves were used). A scoring section for
each observation tallies the adherence score for each encounter
as “all or none”; for example, if hand hygiene was done before
patient contact and after removal of gloves, the adherence score
would be “yes”; if, however, hand hygiene was done before
patient contact but not after removal of gloves, the adherence
score would be “no.” The form, which can capture up to 30
observations, also permits calculation of an overall adherence
rate.
The University of Louisville Hospital in Louisville, Kentucky,
is a 404-bed teaching hospital associated with the University of
Louisville. The “Hand Hygiene and Glove Use Monitoring
Form” is available for the infection control liaisons who do the
observations to use in either paper form or on a personal
digital assistant (PDA). As with the Mayo Clinic form, the
overall adherence rate is either “yes” (hand hygiene is done in
all situations where indicated) or “no” (hand hygiene is done
in some but not all situations where indicated).
REFERENCES
1. World Health Organization (WHO): WHO Guidelines on Hand
Hygiene in Health Care (Advanced Draft): A Summary. Geneva,
Switzerland: WHO, 2006.
2. Institute for Healthcare Improvement (IHI): How-to Guide:
Improving Hand Hygiene. Cambridge, MA: IHI, Apr. 3, 2006.
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Tools/
HowtoGuideImprovingHandHygiene.htm (accessed Dec. 6,
2008).
3. Haas J.P., Larson E.L.: Measurement of compliance with hand
hygiene. J Hosp Infect 66:6–14, May 2007.
4. Gould D.J., et al.: Measuring handwashing performance in health
service audits and research studies. J Hosp Infect 66:109–115, Jun.
2007.
5. Whitby M., McLaws M.-L.: Methodological difficulties in hand
hygiene research (letter). J Hosp Infect 67:194–203, 2007.
6. Pittet D., et al.: Compliance with handwashing in a teaching hos-
pital. Ann Intern Med 130:126–130, 1999.
7. Pittet D., et al.: Effectiveness of a hospital-wide programme to
improve compliance with hand hygiene. Lancet 356:1307–1312,
Oct. 14, 2000. Errata in Lancet 356:2196, Dec. 23–30, 2000.
8. Pittet D., et al.: Hand-cleansing during postanesthesia care.
Anesthesiology 99:530–535, Sep. 2003.
9. Hugonnet S., Perneger T.V., Pittet D.: Alcohol-based handrub
improves compliance with hand hygiene in intensive care units.
Arch Intern Med 162:1037–1043, May 13, 2002.
10. Boyce J.M., Pittet D.: Guideline for Hand Hygiene In Health-
Care Settings: Recommendations of the Healthcare Infection
Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect
Control Hosp Epidemiol 23(Suppl.):S3–S40, Dec. 2002.
11. Taylor L.J.: An evaluation of handwashing techniques—1.Nurs
Times 74:54–55, Jan. 12, 1978.
12. Nicol P., Watkins R.: Hand hygiene monitoring: What it really
measures (letter). J Hosp Infect 67:195–196, Oct. 2007.
13. Sax H., et al.: My five moments for hand hygiene: A user-centered
design approach to understand, train, monitor and report hand
hygiene. J Hosp Infect 67:9–21, Sep. 2007.
14. World Health Organization (WHO), World Alliance for Patient
Safety: Manual for Observers. Geneva, Switzerland: WHO, 2006.
15. van de Mortel T., Murgo M.: An examination of covert observa-
tion and solution audit as tools to measure the success of hand
hygiene interventions. Am J Infect Control 34(3):95–99, 2006.
16. Buchanan D., Huczynski A.: Organizational Behavior, 3rd ed.,
Vol. 7. London: Prentice Hall, 1997.
17. Pittet D.: Promotion of hand hygiene: Magic, hype or scientific
challenge. Infect Control Hosp Epidemiol 23:118–119, Mar. 2002.
18. Roethlisberger F.J., Dickson W.J.: Management and the Worker: An
Account of a Research Program Conducted by the Western Electric
Company, Hawthorne Works, Chicago. Cambridge, MA: Harvard
University Press, 1967.
19. Bittner M., VA Medical Center, Omaha, NE, personal communi-
cation, Nov. 8, 2007.
20. Harris S.: Hand washing takes center stage. AAMC Reporter, Feb.
2007. http://www.aamc.org/newsroom/reporter/feb07/handwash-
ing.htm (accessed Jul. 21, 2008).
21. Nishimura S., et al.: Handwashing before entering the intensive
care unit: what we learned from continuous video-camera surveil-
lance. Am J Infect Control 27:367–369, Aug. 1999.
22. Vandenbroucke J.P., et al.: Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE): Explanation
and elaboration. Ann Intern Med 147:W163–W194, Oct. 16,
2007.
23. Harrington L., et al.: Reliability and validity of hand hygiene
measures. J Healthc Qual 4:20–29, 2007.
24. McAteer J., et al.: Development of an observational measure of
health care worker hand-hygiene behaviour: The Hand-Hygiene
Observation Tool (HHOT). J Hosp Infect 68:222–229, Mar. 2008.
25. Nolan T., Berwick D.M.: All-or-none measurement raises the bar
on performance. JAMA 295:1168–1170, Mar. 8, 2006.
33
Observing Adherence to Hand Hygiene Guidelines
34
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 3-1.
Examples of Research Articles That Compare Adherence Rates on Opportunities for
Different Indications
Article
Bahal A., et al.: Hand hygiene
compliance: Universally better post-
contact than pre-contact in health care
workers in the UK and Australia.
British Journal of Infection Control
8(1):24–28, 2007.
Novoa A.M., et al.: Evaluation of hand
hygiene adherence in a tertiary
hospital. Am J Infect Control
35:676–683, Dec. 2007.
Eckmanns T., et al.: Compliance with
antiseptic hand rub use in intensive
care units: The Hawthorne effect.
Infect Control Hosp Epidemiol
27:931–934, Sep. 2006.
Wendt C., Knautz D., von Baum H.:
Differences in hand hygiene behavior
related to the contamination risk of
health care activities in different groups
of health care workers. Infect Control
Hosp Epidemiol 25:203–206, Mar.
2004.
Bischoff W.E., et al.: Handwashing
compliance by health care workers:
The impact of introducing an
accessible, alcohol-based hand
antiseptic. Arch Intern Med
160:1017–1021, Apr. 10, 2000.
Opportunities Measured
Before and after patient contact.
Before or after patient contact.
Before and after patient care procedures
(such as care of catheters, wounds,
ventilation care, urinary catheters,
ventricle drainage; preparation of
intravenous solutions; and any direct
patient contact).
HH opportunities, based on the 15-item
Fulkerson scale in intensive care units
(ICUs) and general nursing wards.
Before and after all events with high risk
of microbial transmission, including
contact with mucous membranes, non-
intact skin, secretions or excretions; and
manipulations of vascular lines or other
tubes.
Findings
The patterns of post-contact adherence
and non-adherence strongly suggest
that hand hygiene (HH) practice in
both study countries is primarily self-
protective rather than a patient
safety–centered practice (better after
patient care than before patient care).
A total of 1,254 opportunities for HH
were observed in 247 staff members:
• 12.8% before patient contact
• 25.6% after patient contact
Observations were made during two
observation periods (first one covert,
second one overt):
• Covert, before procedures/contact:
24%
• Covert, after procedures/contact:
35%
• Overt, before procedures/contact:
31%
• Overt, after procedures/contact:
47%
During the study period, 2,138
observations were made, with nearly
two-thirds of the observations
occurring on general nursing wards.
Health care workers (HCWs) on
general wards tended to perform HH
more frequently (72.4%) than those in
the ICUs (51.8%).
This study included observation of
1,575 HH opportunities in one
medical ICU, one cardiac surgery
ICU, and one general medical ward.
HH adherence before and after an
intervention in the medical intensive
care unit showed improvement in HH
adherence after the introduction of
35
Observing Adherence to Hand Hygiene Guidelines
Appendix 3-1. (continued)
Bischoff (cont.)
Pittet D., Mourouga P., Perneger T.V.:
Compliance with handwashing in a
teaching hospital. Ann Intern Med
130:126–130, Jan. 19, 1999.
Watanakunakorn C., Wang C., Hazy
J.: An observational study of hand
washing and infection control practices
by health care workers. Infect Control
Hosp Epidemiol 19:858–860, Nov.
1998.
Thompson B.L., et al.: Handwashing
and glove use in a long-term-care
facility. Infect Control Hosp
Epidemiol 18:97–103, Feb. 1997.
Type of patient care activity:
• After each patient contact
• Between care of a dirty and a clean
body site
• After contact with body fluid
• Before and after intravenous care,
wound care, respiratory care, and
urinary care
• After glove removal
• After indirect patient contact or
hospital maintenance
After performing various patient care
activities:
• Examining the patient
• Emptying urine bag
• Bathing the patient
• Suctioning or wound care
• Inserting intravenous lines
• Wound care
Before, during, and after patient contact.
alcohol-based hand rub (ABHR) at
each patient bed:
• Baseline, before patient contact:
10%
• Baseline, after patient contact: 22%
• Post-intervention, before patient
contact: 23%
• Post-intervention, after patient
contact: 48%
In this study, of 2,834 observed
opportunities for HH, adherence was
lower:
• Before IV care: 39%
• Before respiratory care: 18%
• Care between a dirty and clean
body site: 11%
Adherence was higher:
• After contact with body fluid: 63%
• After wound care: 58%
The overall prevalence of HH was
30.2% (207 of 686 opportunities).
HH was performed more often for
some activities than others:
• Examining the patient: 47.5%
• Emptying urine bag: 44.1%
• Bathing the patient: 83.3%
• Suctioning: 20.7%
• Wound care: 23 %
• Inserting intravenous lines: 33.3%
In this observational study of 230 staff
in a long term care facility, staff washed
their hands when indicated in 189
patient interactions, as follows:
• 27% before patient contact
• 0% during patient care
• 63% after patient contact
Article Opportunities Measured Findings
36
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 3-2.
Examples of Research Articles That Examine Adherence by Intensity, Frequency, Risk
of Opportunity, and Other Factors
Article
Rupp M.E., et al.: Prospective,
controlled, cross-over trial of
alcohol-based hand gel in
critical care units. Infect
Control Hosp Epidemiol
29:8–15, Jan. 2008.
Novoa A.M., et al.: Evaluation
of hand hygiene adherence in a
tertiary hospital. Am J Infect
Control 35:676–683, Dec.
2007.
Eckmanns T., et al.:
Compliance with antiseptic
hand rub use in intensive care
units: the Hawthorne effect.
Infect Control Hosp
Epidemiol 27:931–934, Sep.
2006.
Larson E.L., Albrecht S.,
O'Keefe M.: Hand hygiene
behavior in a pediatric
emergency department and a
pediatric intensive care unit:
comparison of use of 2
dispenser systems. Am J Crit
Care 14:304–311, Jul. 2005.
Health Care Setting
Two intensive care units
(ICUs)
Hospitalwide cross-
sectional study
Five ICUs in two
university hospitals
Two units at a large
pediatric hospital:
• Emergency department
• Pediatric intensive care
unit (PICU)
Measure of Intensity, Risk, etc.
Overall, 12.3 opportunities per hour
were recorded across both ICUs.
Health care worker (HCW) activities
were classified according to risk:
• High risk: Prior to any patient
contact
• Intermediate risk: After patient
exam, wound contact, aseptic
technique, contact with bedpan
• Low risk: Before/after
environmental contact
Number of opportunities per hour:
• Covert observation period (observer
was stationary at charting area): 9.4
opportunities per hour.
• Overt observation period (observer
mobile, followed HCWs during
procedures): 18.7 opportunities per
hour.
• Study personnel observed 5,568
indications for HH over 306 hours
of observation, for an average of
18.2 indications per hour.
• HH occurred in 2,136 of those
observed, for a mean of 7.0
episodes per hour.
• The mean number of indications
for HH per patient was
significantly greater in the PICU
than in the emergency department
(6.12 vs. 5.16 indications,
respectively; P=.02).
Health Care Worker Adherence
Rates of hand hygiene (HH)
adherence in the two study periods:
ICU 1:
• 38% when no alcohol-based hand
rub (ABHR) was available
• 69% when ABHR was available
ICU 2:
• 37% when no ABHR was available
• 68% when ABHR was available
Rates of HH adherence by risk of
cross-infection:
• Low risk: 13.9%
• Intermediate risk: 31.8%
• High risk: 13.7%
The findings suggested that HCWs
perform HH for their own protection
rather than to protect the patient.
Rates of HH adherence in the two
periods:
• Covert observation period: 29%
• Overt observation period: 45%
• Rates of adherence did not differ
significantly between the
emergency department and the
PICU (35% vs. 41%, respectively;
P = .07).
37
Observing Adherence to Hand Hygiene Guidelines
Appendix 3-2. (continued)
Lam B.C., Lee J., Lau Y.L.:
Hand hygiene practices in a
neonatal intensive care unit: a
multimodal intervention and
impact on nosocomial
infection. Pediatrics
114:e565–e571, Nov. 2004.
Pittet D., et al.: Hand hygiene
among physicians:
Performance, beliefs, and
perceptions. Ann Intern Med
141:1–8, Jul. 6, 2004.
Wendt C., Knautz D., von
Baum H.: Differences in hand
hygiene behavior related to the
contamination risk of health
care activities in different
groups of health care workers.
Infect Control Hosp
Epidemiol 25:203–206, Mar.
2004.
Neonatal intensive care
unit (NICU) in a
university hospital
Hospital wards throughout
a large teaching hospital
General wards and ICUs
in a teaching hospital
High-risk procedures, HH before and
after:
• Invasive procedure; wound, mucous
membrane or body fluid contact
• Administration of intravenous
fluids
• Suctioning
• Prolonged patient contact (bathing,
changing linen, physiotherapy, etc)
Low-risk procedures, HH before and
after:
• When giving oral medications
• Administration of tube feedings
• Skin contact (touching, holding)
Physician workload, estimated by the
number of observed opportunities for
HH per hour of patient care for each
physician observation (activity index).
Level of risk for cross-transmission:
• High risk for cross-transmission:
Prior to patient care or between dirty
and clean site on same patient; before
intravenous or arterial care; before
urinary, respiratory, or wound care
• Medium risk for cross-transmission:
After contact with patient; after
intravenous or arterial care; after
urinary, respiratory, or wound care
after contact with body fluid
• Low risk for cross-transmission:
Other conditions
Risk of contamination, 15-point
Fulkerson scale, ranking contacts from
clean to dirty:
• “Clean” activities: rank 1–7
• “Dirty” activities: rank 8–15
HH adherence, general ward vs. ICU.
Rates of HH adherence before the
researcher’s educational intervention
with staff:
Before (and after) patient contact:
• High risk procedures: 35%, (41%)
• Low risk procedures: 43%, (37%)
Rates of HH adherence after the
intervention:
Before (and after) patient contact:
• High risk procedures: 60%, (71%)
• Low risk procedures: 49%, (51%)
HH improved over the two study
periods, but HH after high-risk
procedures remained higher than that
for low-risk procedures.
Rates of HH adherence by physician
workload:
• < 5 opportunities per hour: 63.3%
• > 5 opportunities per hour: 52%
Rates of HH adherence by risk:
• Low-medium risk: 62.9%
• High risk: 36.9%
Opportunities for HH related to
high-risk for cross-transmission and
those related to high workload were
associated with reduced adherence.
The lowest use of ABHR among all
staff occurred after contact with items
that had had no patient contact, and
the highest use occurred after contact
with feces. High rates of ABHR use by
nurses was observed after contact with
sterile materials (low-risk activity),
whereas physicians had a high use of
ABHR after contact with excretions
(high-risk activity). HH compliance
was higher on regular wards (72.4%)
than in the ICUs (51.8%), believed to
have been due to the higher workload
during care of critically ill patients.
Article Health Care Setting Measure of Intensity, Risk, etc. Health Care Worker Adherence
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 3-2. (continued)
Bittner M.J., et al.: Limited
impact of sustained simple
feedback based on soap and
paper towel consumption on
the frequency of hand washing
in an adult intensive care unit.
Infect Control Hosp
Epidemiol 23:120–126, Mar.
2002.
O'Boyle C.A., Henly S.J.,
Larson E.: Understanding
adherence to hand hygiene
recommendations: the theory
of planned behavior. Am J
Infect Control 29:352–360,
Dec. 2001.
Pittet D., Mourouga P.,
Perneger T.V.: Compliance
with handwashing in a
teaching hospital. Ann Intern
Med 130:126–130, Jan. 19,
1999.
Two ICUs in a Veterans
Affairs Medical Center
Adult ICUs and post-
ICUs in four metropolitan
hospitals in the Midwest
Sample of various clinical
staff in different hospital
wards in a large teaching
hospital:
• Medical ward
• Surgical ward
• Obstetrics/gynecology
ward
• Pediatrics
• Intensive care
Nurse staffing ratios (workload) and
their impact on estimated hand
washing episodes (EHWEs) was
studied. Estimated hand washing
episodes (EHWEs), calculated by
weighing the soap and towels at each
sink at the beginning and end of each
four-hour observation session. Using a
regression model that employed
changes in soap and towel weight, they
calculated EHWEs that corresponded
to the changes in soap and towel
weight.
• Estimates of adherence to HH
recommendations, via observation
and self-report
• Relationship among motivation,
adherence and intensity of nursing
unit activity
• Test of an explanatory model for
HH adherence based on the theory
of planned behavior
Example of variation in number of
opportunities per hour:
• Pediatrics: 24.4 opportunities per
hour
• Intensive care: 43.4 opportunities
per hour
Risk of contamination, based on the
15-point Fulkerson scale, ranking
contacts from clean to dirty:
• High risk:
Prior to patient care or between dirty
and clean site on same patient
• Medium risk:
After contact with patient; after
In the two study ICUs, EHWE
decreased when the occupied bed-to-
nurse ratio increased.
• HH adherence via observation was
highest for “after completion of
care” (87.08%) and “after direct
contact with body substances”
(87.12%).
• Overall adherence rate was 70%
across the 1,246 indications for HH.
• The association between self-
reported and observed HH
adherence was positive but low.
• Intensity of activity in the units at
the time of observation was signifi-
cantly and negatively associated with
adherence to HH (lower adherence
when units were busier).
• Observed HH action was predicted
only when the activity of the
nursing unit was a variable.
Rates of HH adherence by ward:
• Medical ward: 52%
• Surgical ward: 47%
• Obstetrics/gynecology ward: 48%
• Pediatrics: 59%
• Intensive care: 36%
Rates of HH adherence by risk of
contamination:
• High risk: 38%
• Medium risk: 49%
• Low risk: 52%
Rates of HH adherence based on the
intensity of patient care (activity index):
• < 20: 58%
38
Article Health Care Setting Measure of Intensity, Risk, etc. Health Care Worker Adherence
39
Observing Adherence to Hand Hygiene Guidelines
Appendix 3-2. (continued)
Pittet D., et al.: Effectiveness
of a hospital-wide programme
to improve compliance with
hand hygiene. Lancet
356:1307–1312, 2000.
Larson E.L., et al.: A
multifaceted approach to
changing handwashing
behavior. Am J Infect Control
25:3–10, Feb. 1997.
Seven hospitalwide
observation periods were
conducted from 1994 to
1997. Data were obtained
from 2,629 prespecified
20-minute observation
sessions throughout the
day and night. A
hospitalwide multimodel
HH improvement
program with an emphasis
on bedside use of alcohol-
based hand disinfection
was implemented in
January 1995. The
program included
customized unit-level
posters, strong staff
engagement, performance
feedback, and individual
bottles of hand gel.
Two ICUs:
• ICU 1 (interventional
unit)
• ICU 2 (control unit)
contact with body fluid; after patient
care
• Low risk:
Activity involving indirect pt contact
or hospital maintenance
Intensity of patient care (estimated by
the number of opportunities for HH
per observation period, referred to as
the activity index).
Risk of contamination, based on the
15-point Fulkerson scale, ranking
contacts from clean to dirty:
• High risk: Prior to patient care or
between dirty and clean site on
same patient
• Medium risk: After contact with
patient; after contact with body
fluid; after patient care
• Low risk: Activity involving indirect
patient contact or hospital
maintenance
Intensity of patient care (estimated by
the number of opportunities for HH
per observation period, referred to as
the activity index).
Number of opportunities per hour:
• ICU 1: 8.7 opportunities per hour
• ICU 2: 8.8 opportunities per hour
• 21–40: 51%
• 41–60: 40%
• > 60: 37%
When the intensity exceeded 10
opportunities per hour, the
compliance decreased on average by
5% (±2%) for every additional 10
opportunities. Overall, HH adherence
was lower in intensive care wards than
in other wards; higher-risk activities
were associated with low adherence to
hand washing; and adherence was
worse when the activity level was high.
Data were obtained on 20,082
opportunities. There was a significant
improvement in compliance in the
ICU and medical and surgical wards,
with nonsignificant trends in
obstetrics/gynecology and pediatrics
units. Compliance rates were lower in
high-risk activities than medium- or
low-risk activities, however all groups
improved significantly over time.
Intensity of patient care was constant
during the study period and
significantly improved over time at all
levels of demand
Rates of HH adherence by unit:
ICU 1:
• 56% at baseline
• 76% at follow-up
ICU 2:
• 55% at baseline
• 65% at follow-up
Article Health Care Setting Measure of Intensity, Risk, etc. Health Care Worker Adherence
40
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 3-2. (continued)
Meengs M.R., et al.: Hand
washing frequency in an
emergency department.
Ann Emerg Med
23:1307–1312, Jun. 1994.
Emergency department in
a tertiary referral teaching
hospital
Risk of contamination, 15-point
Fulkerson scale, ranking contacts from
clean to dirty:
• “Clean” activities: rank 1–7
• “Dirty” activities: rank 8–15
Gloves used, break in technique
defined as not performing HH after
removing gloves and proceeding to
another patient or activity
Number of HH opportunities per
hour: 11.7
Rates of HH adherence by clean vs.
dirty vs. gloved activities:
• Clean activity: 18.4%
• Dirty activity: 50%
• Gloved activity; 64.8%
Comparison of gloved and ungloved
contacts showed that the use of gloves
increased hand washing frequency
significantly (p < 0.0001). The
authors thought this may be due to
the desire to remove powder that
remains on their hands after glove
removal.
Appendix 3-3.
Examples of Research Articles That Compare Adherence Rates by Category of
Health Care Worker
Author/Article
Rupp M.E., et al.: Prospective,
controlled, cross-over trial of
alcohol-based hand gel in
critical care units. Infect
Control Hosp Epidemiol
29:8–15, Jan. 2008.
Trick W.E., et al.: Multicenter
intervention program to
increase adherence to hand
hygiene recommendations and
glove use and to reduce the
incidence of antimicrobial
resistance. Infect Control Hosp
Epidemiol 28:42–49, Jan.
2007.
Description
This was a two-year,
prospective, controlled,
crossover trial of alcohol-based
hand rub (ABHR) in 2 adult
medical-surgical units in a
university-associated tertiary
care teaching hospital in
Nebraska. Hand hygiene (HH)
was observed in health care
workers (HCWs) in both units,
before and after ABHR was
made available.
This was a prospective study of
three intervention hospitals and
a control hospital in Illinois over
a three-year period. Both the
intervention and control
hospitals introduced or
increased the availability of
ABHR; the intervention
hospitals also had educational
programs and developed a
poster campaign. Study
personnel conducted at least 4
Category of
Health Care Worker
• Nurses
• Physicians
• Others (allied health
personnel)
• Nurses
• Physicians
• Others
Findings
A total of 3,678 opportunities for HH were
identified. While HH adherence improved
after the introduction of ABHR, differences
between the different categories of HCWs
were still noticeable in the two units:
• Nurses: 66% (unit 1)
74% (unit 2)
• Physicians: 82% (unit 1)
67% (unit 2)
• Others: 63% (unit 1)
6% (unit 2)
The researchers observed 6,948 HH
opportunities in the three intervention and
one control hospitals. Adherence rates over
the study period in the four hospitals were:
• Nurses: 42%
• Physicians: 39%
• Others: 20%
Article Health Care Setting Measure of Intensity, Risk, etc. Health Care Worker Adherence
41
Observing Adherence to Hand Hygiene Guidelines
Appendix 3-3. (continued)
Rosenthal V.D., Guzman S.,
Safdar N.: Reduction in
nosocomial infection with
improved hand hygiene in
intensive care units of a
tertiary care hospital in
Argentina. Am J Infect
Control 33:392–397, Sep.
2005.
Wendt C., Knautz D., von
Baum H.: Differences in hand
hygiene behavior related to the
contamination risk of health
care activities in different
groups of health care workers.
Infect Control Hosp
Epidemiol 25:203–206, Mar.
2004.
Pittet D., Mourouga P.,
Perneger T.V.: Compliance
with hand washing in a
teaching hospital. Ann Intern
Med 130:126–130, Jan. 19,
1999.
Pittet D., et al. Effectiveness of
a hospital-wide programme to
improve compliance with hand
hygiene. Lancet
356:1307–1312, 2000.
hours of observation in three
units in each hospital per
month, with observation
periods done on all shifts for 60
minutes each.
HH was observed in two
intensive care units (ICUs) in a
hospital in Argentina before and
during the implementation of a
HH program. Trained staff
observed HH practices at
random times twice a week,
including all work shifts, for 30-
minute intervals during the two
periods.
This observational study was
done in general wards and ICUs
in a large teaching hospital in
Germany between January and
September 2000. Multiple
trained observers noted each
patient contact and ranked each
on the 15-item Fulkerson scale.
Observations were completed in
a sample of 48 different wards
(medical, surgical,
obstetrics/gynecology, pediatric
ward, and ICU) in a teaching
hospital in Switzerland during a
two-week period in December
1994. Five trained infection
preventionists (IPs) conducted
20-minute observation periods
distributed randomly during the
day and night over 14 days.
Seven hospitalwide observation
periods were conducted from
1994 to 1997. Data was
obtained from 2629 prespecified
20-minute observation sessions
throughout the day and night.
A hospitalwide multimodel HH
• Nurses
• Physicians
• Ancillary staff
• Nurses
• Physicians
• Nurses
• Physicians
• Nursing assistants
• Others
• Nurses
• Physicians
• Nursing assistants
• Other HCWs
A total of 4,347 opportunities were
identified in HCWs. Overall, HH adherence
improved significantly between the two
periods (23.1% to 64.5%, p < .0001). As
with many other studies, adherence among
physicians was lower than among other
HCWs:
• Nurses: 59.6%
• Physicians: 30.8%
• Ancillary staff: 37.1%
During the study period 2,138 observations
were made. Overall, nurses had higher
adherence with HH indications (67.9%)
than physicians (57.5%).
The study observers recorded 2,834
opportunities for HH among 1,043 HCWs,
with much variation in HH adherence
within different categories of HCWs:
• Nurses: 52%
• Physicians: 30%
• Nursing assistants: 47%
• Others: 38%
Data were obtained on 20,082
opportunities. The distribution of
opportunities according to HCW type
remained similar over time, with nurses
contributing a mean of 68.8%, nursing
assistants 18.0%, physicians 8.3%, and other
HCWs 4.9%. There was a significant
Author/Article Description Category of Findings
Health Care Worker
42
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 3-3. (continued)
Watanakunakorn C., Wang C.,
Hazy J.: An observational
study of hand washing and
infection control practices by
health care workers. Infect
Control Hosp Epidemiol
19:858–860, Nov. 1998.
Meengs M.R., et al.: Hand
washing frequency in an
emergency department.
Ann Emerg Med
23:1307–1312, Jun. 1994.
improvement program with an
emphasis on bedside use of
alcohol-based hand disinfection
was implemented in January
1995. The program included
customized unit-level posters,
strong staff engagement,
performance feedback, and
individual bottles of hand gel.
During a six-week period, a
medical student conducted an
observational study in an Ohio
teaching hospital. This trained
observer recorded whether the
HCWs washed hands after
performing various patient care
activities (e.g., examining the
patient, emptying urine bag,
suctioning or wound care,
inserting intravenous lines).
This observational study was
conducted solely in the
emergency department of a
large tertiary care private
teaching hospital in Indiana
over a four-week period. Patient
contacts and activities for each
emergency department staff
member were recorded during
three-hour observation periods.
Data were collected during day
and evening shifts, both
weekday and weekend.
• Nurses
• Residents
• Attending physicians
• Others
• Nurses
• Residents
• Staff physicians
difference in the amount of improvement by
type of HCW. Though nurses’ and nursing
assistants’ compliance rose significantly,
average compliance remained low among
physicians and other HCWs, with no
significant trends over time. However,
physicians did switch from hand washing to
using hand gel.
Overall adherence to HH was 30.2% (207 of
686 opportunities), but there were marked
differences between the categories of HCWs,
with a surprisingly higher adherence rate for
residents and attending physicians:
• Residents: 59.2%
• Attending physicians: 37.4%
• Nurses: 32.5%
• Others: 4.2%
Out of the 409 total HH opportunities
observed, HH occurred 32.2% of the time.
Nurses practiced HH more often than
residents or attending staff:
• Nurses: 58.2%
• Residents: 18.6%
• Staff physicians: 17.2%
Author/Article Description Category of Findings
Health Care Worker
Observing Adherence to Hand Hygiene Guidelines
Appendix 3-4.
Examples of Structured Approaches for Observations
Researcher(s)
Rupp M.E., et al.:
Prospective,
controlled, cross-
over trial of
alcohol-based hand
gel in critical care
units. Infect Control
Hosp Epidemiol
29:8–15, Jan. 2008.
Trick W.E., et al.:
Multicenter
intervention
program to increase
adherence to hand
hygiene
recommendations
and glove use and to
reduce the incidence
of antimicrobial
resistance. Infect
Control Hosp
Epidemiol
28:42–49, Jan.
2007.
Study
Setting/Design
Two general adult
medical-surgical
intensive care units
(ICUs) at a
university-associated
tertiary care teaching
hospital in
Nebraska, from
August 1, 2001, to
September 30, 2003.
Prospective study in
three intervention
hospitals and a
control hospital in
Illinois over a three-
year period.
Objective was to
monitor the
adherence to HH
and glove use
recommendations
and the incidence of
multiple–drug-
resistant organisms
(MDRO) in clinical
cultures. Both the
intervention and
control hospitals
introduced or
increased the
availability of
ABHR; the
intervention
hospitals also had
educational
programs and
developed a poster
campaign.
Observation
Periods
Observations were
done in 20-minute
increments over 2-
week periods, every
60 days, for the
duration of the
study.
• Study personnel
conducted at least
four hours of
observation in
three units in
each hospital per
month.
• Observation
periods lasted 60
minutes.
• Observations
were done on all
shifts.
Observation
Methodology
Unobtrusive observa-
tions were done on
the two units.
Because the observers
had regular duties in
the ICUs, it was not
apparent to health
care workers
(HCWs) when hand
hygiene (HH) obser-
vations were being
done. The location of
observations was
determined by ran-
domization of the
room numbers.
• Observers consid-
ered each
HCW–patient
encounter as a
single opportunity
for HH.
• An encounter
included HCW
contact with a
patient or an envi-
ronmental surface
in the patient’s
room.
• Only single obser-
vations of any
individual HCW
were permitted (to
avoid bias in the
study resulting
from multiple
observations of
any single HCW).
• To control for
increased aware-
ness of the
observer by
HCWs being
observed, the
order in which
each HCW was
Observers
Ten trained individu-
als (six infection
preventionists [IPs],
four trained assis-
tants) participated as
observers. Ninety
percent of an individ-
ual’s assessments had
to agree with an IP’s
before that person
could participate as
an observer.
• Three observers
(not infection
control staff )
were trained by
the same person.
• Interrater
reliability
required 80%
agreement among
the observers as
to whether HH
had occurred for
an entire
observation
period before
unsupervised
observations were
permitted.
• Training included
tours of the
observation units
and discussions
about each data
element.
Comments
A total of 17,994 minutes
of observation were done
over the study period,
with 3,678 HH
opportunities recorded.
Adherence rates improved
after the introduction of
alcohol-based hand rub
(ABHR) (from 37% to
68% in one unit and from
38% to 69% in the
other).
Observers recorded 6,948
HH opportunities during
1353 observation sessions.
Both glove use and
adherence to hand
hygiene improved
significantly in the
intervention hospitals
(74%, 80% and 77%) but
not at the control hospital
(59%)
43
44
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 3-4. (continued)
Larson E.L.,
Albrecht S., O'Keefe
M.: Hand hygiene
behavior in a
pediatric emergency
department and a
pediatric intensive
care unit:
Comparison of use
of 2 dispenser
systems. Am J Crit
Care 14:304–311,
Jul. 2005.
Lam B.C., Lee J.,
Lau Y.L.: Hand
hygiene practices in
a neonatal intensive
care unit: a
multimodal
intervention and
impact on
nosocomial
infection. Pediatrics
114:e565–e571,
Nov. 2004.
Crossover
intervention trial in
an emergency
department and a
pediatric intensive
care unit (PICU) at
a large pediatric
hospital over a four-
month period. The
frequency of HH
episodes was
measured by using
both direct
observation and
electronic counters
in dispensers.
Study was
conducted over two
four-week periods in
the 12-bed neonatal
intensive care unit
(NICU)of a hospital
in China:
• First study
period: baseline
data collection.
• Second study
period: 6 months
after the
conclusion of an
intervention that
included HH
education,
• Study personnel
conducted 1-hour
observations, for
a total of
approximately 15
hours per week.
• Observations
were done on day
and night shifts.
Observations
occurred on daytime
shifts. A target
NICU patient was
randomly selected by
drawing lots before
each observation
period, which lasted
8 hours. All staff
who contacted the
target patient were
observed; visitors
were also observed.
observed was
recorded (first
HCW observed,
second HCW
observed, etc).
• For each observa-
tion in a unit, the
research assistant
took a vantage
point that permit-
ted observation of
the maximum
number of con-
tacts between
patients and staff.
For most observa-
tion periods, two
to five patients
and their sur-
roundings were
captured in the
data collected.
• Staff member HH
observations were
recorded without
identifiers, using
the eight indica-
tions in the
CDC’s 2002 HH
guideline.
Overt observation
occurred under the
guise of medical
students collecting
data on the activities
in the NICU. For
each observed contact
with the target
patient, there were
two opportunities for
HH that were
recorded separately:
before and after. Data
were recorded using a
standard computer-
based data form and
included details of
• Three research
assistants
• Before the study
began, interrater
reliability was
established
between the
investigators and
the research
assistants to
ensure more than
95% agreement.
• The observer had
one week of
training to
become familiar
with the NICU
procedures and
setting.
• The consistency
of observations
was validated by
checking on
selected episodes
immediately after
each observation
period by one of
the authors.
A total of 306 hours of
observation were
completed (split evenly
between the two units).
Most of the observations
took place on the day shift
(272/306, 88.9%).
Total adherence rates did
not differ significantly
between the emergency
department and the
PICU.
First observation period:
• 666 patient contacts
over 234 patient hours
were observed.
• Average number of
contacts per patient per
hour was 2.8.
Second observation
period:
• 317 patient contacts
over 174 patient hours
were observed.
• Average number of
contacts per patient
per hour was 1.8
(possibly due to
enhanced clustering of
Researcher(s) Study Observation Observation
Setting/Design Periods Methodology Observers Comments
45
Observing Adherence to Hand Hygiene Guidelines
Appendix 3-4. (continued)
Pittet D., et al.:
Hand hygiene
among physicians:
Performance, beliefs,
and perceptions.
Ann Intern Med
141:1–8, Jul. 6,
2004.
Wendt C., Knautz
D., von Baum H.:
Differences in hand
hygiene behavior
related to the
contamination risk
of health care
activities in different
groups of health care
workers. Infect
Control Hosp
Epidemiol
25:203–206, Mar.
2004.
enhancement of a
minimal handling
protocol and
clustering of care,
and liberal
provision of
ABHR. The
interventions
occurred over a
12-month period.
Cross-sectional study
of physician
practices, attitudes,
and beliefs on HH
in a teaching
hospital in
Switzerland over a
six-month period.
All 1,266 physicians
(staff physicians,
fellows, residents,
and medical
students) who were
practicing were
eligible for inclusion
in the study and
were informed by
mail prior to the
onset of the study.
General wards and
ICUs in a large
teaching hospital in
Germany between
January and
September 2000.
Observations were
distributed
throughout the
hospital over the
study period in
order to allow the
observer to obtain a
balanced
distribution of
observation periods
in the organization.
Observations were
performed on all
shifts and on all days
of the week, though
most occurred on
weekdays during the
day shift.
each patient (number
of indwelling
lines/tubes). HH
technique was also
assessed, using a
checklist of 15
essential steps for
hand washing.
Individual physicians
were observed during
routine patient care;
each was observed
only once. Each
physician completed
a self-report question-
naire on cognitive
factors related to HH
immediately after the
observed patient
contact.
Opportunities for
HH were stratified
into three categories
(high, medium, and
low risk for cross-
transmission).
HCWs were
observed for 15
different types of
contact, ranked from
clean to dirty (using
the Fulkerson scale).
Observers monitored
HCWs during
routine work on the
units intermittently
during the work
shift of the observer.
Data were stratified
by unit (ICU or
general ward) and
profession.
A hospital
epidemiologist
recorded all
potential
opportunities among
selected physicians.
Five infection
control nurses, 21
nursing students,
and 15 medical
students participated
as observers. They
were trained in
observing nurses and
physicians and
recording their HH
behavior.
patient care).
HH compliance before
patient contact during the
first study period was
40%; it improved to 53%
in the second study
period.
The study included more
than 125 hours of
observation; 163
physicians were observed
during 573 patient care
episodes; this provided
887 opportunities for HH
with 57% HH adherence.
Adherence differed
between medical
specialties.
During the study, 2,138
observations were made,
with nearly two-thirds of
the observations made on
regular shifts. In addition:
• HCWs on regular
wards performed HH
more frequently than
did those in ICUs
(72.4% vs. 51.8%).
• Nurses performed HH
more often than
physicians (67.9% vs.
57.5%).
Researcher(s) Study Observation Observation
Setting/Design Periods Methodology Observers Comments
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 3-4. (continued)
Earl M.L., Jackson
M.M., Rickman
L.S.: Improved rates
of compliance with
hand antisepsis
guidelines: a three-
phase observational
study. Am J Nurs
101:26–33, Mar.
2001.
Pittet D., et al.:
Effectiveness of a
hospital-wide
programme to
improve compliance
with hand hygiene.
Lancet
356:1307–1312,
Oct. 14, 2000. Errata
in Lancet 356:2196,
Dec. 23–30, 2000.
Three-phase
observational study
in two ICUs at a
university medical
center in California
over a five-month
period:
• 20-bed surgical
ICU
• 13-bed medical
ICU
Observational study
in a large teaching
hospital in Switzer-
land (following the
baseline survey in
1994, described in
Pittet 1999). Seven
surveys were done
twice a year in June
and December, from
1994 to 1997.
Phase 1: determined
baseline with soap-
and-water hand
washing.
Phase 2: two to six
weeks following the
installation of 73
ABHR dispensers
both inside and
outside patient
rooms, HH was
observed.
Phase 3: observation
period conducted
10-14 weeks post-
installation:
• Observation
sessions were
scheduled at
varied times
throughout the
day and night in
all three phases.
• Observation
sessions lasted
either four or
eight hours, with
two observers
assigned to each
session. They
observed one
ICU during the
first half of the
session and then
moved to the
other unit in the
second half.
Twenty-minute
observations were
done at prespecified
times throughout
the day and night.
• Observers
recorded
indications for
HH during
patient care
episodes and
noted whether
HH actually
occurred.
• For each episode
of care there were
at least two
instances for HH
adherence: before
and after patient
contact.
• HCWs were
classified as
ancillary staff,
nursing staff, or
physicians.
• While the
observations were
done overtly, if
approached by
staff, the
observers simply
said they were
doing an
infection control
study.
HCWs were not
aware of the
observation
schedule. Observers
were as unobtrusive
as possible. HCWs
observed nurses,
physicians, nursing
assistants, and
others.
• Five observers, all
public health
graduate
students,
conducted
observations at
varied times
during day and
night shifts.
• Each was trained
in the study’s
criteria and
methods.
• Interobserver
reliability of 65
observations was
tested, using a
third observer
who worked
simultaneously
with one of the
two observers
assigned to a
specific session
and unit.
• Infection control
nurses performed
the observation.
• Recorded
potential
opportunities for
and actual
performance of
HH.
• Interrater
reliability was
In a total of 402 hours of
observation across the
three phases, 3,015
opportunities for HH
were recorded and in
1,481 HH was performed.
2,509 of the total 2,629
observation periods
resulted in data being
collection, with a total of
almost 834 hours of
observation. Data were
collected on 20,082
opportunities for HH.
Overall adherence
improved from 47.6% in
1994 to 66.2% in
46
Researcher(s) Study Observation Observation
Setting/Design Periods Methodology Observers Comments
47
Observing Adherence to Hand Hygiene Guidelines
Appendix 3-4. (continued)
Pittet D., et al.:
Compliance with
handwashing in a
teaching hospital.
Ann Intern Med
130:126–130, 1999.
Larson E.L., et al.: A
multifaceted
approach to
changing hand
washing behavior.
Am J Infect Control
25:3–10, Feb. 1997.
Observational study
in a sample of 48
different wards
(medical, surgical,
obstetrics/gynecolog
y, pediatric ward,
and ICU) in a large
teaching hospital in
Switzerland during a
two-week period in
December 1994.
Quasi-experimental
study in two
intensive care units
(ICUs) in a 350-bed
tertiary care
academic health
center in
Washington, DC,
over a 14-month
period:
• 7-bed
neurological ICU
(experimental
Twenty-minute
observation periods
distributed
randomly during the
day and night over
14 days.
HH behavior in the
two ICUs was
observed in each of
five study phases:
• Baseline
observation
period;
• Sinks converted
from random to
manual mode;
• Sinks converted
to automatic
mode;
In most areas, HCWs
providing care in a
randomly selected
room were observed;
in the ICU, HCWs
providing care to two
patients in randomly
selected beds were
observed. HCWs
observed included
nurses, physicians,
nursing assistants, and
others. Data were
recorded on a form
that had been
pretested and adjusted
in a pilot study.
• Observers
recorded whether
nursing personnel
washed hands
when indicated,
before or after
patient contacts
or critical
procedures.
• Hand washing
frequency of
nursing personnel
was observed at
recorded during
at least 10% of
the observation
periods in which
two or three
observers worked
simultaneously;
• Interrater
reliability was
high (kappa
values = 0.92;
range 0.79–1.0)
• Five trained infec-
tion control
nurses.
• Recorded poten-
tial opportunities
for and actual per-
formance of HH.
• Interrater reliabil-
ity was evaluated
during 110 moni-
toring sessions (48
before and 62
during the study)
in which two or
three observers
worked simultane-
ously.
• Interrater reliabil-
ity was high
(kappa values =
0.92, range
0.81–1.0)
• Five observers
(two investiga-
tors, three
nursing students)
• Trained in the
use and interpre-
tation of hand
washing indica-
tions and use of
the data collec-
tion form.
• Interrater
reliability testing
December 1997 (p <
0.001). HH improved
significantly among nurses
and nursing assistants but
remained poor among
physicians.
In 307 sessions totaling
105 hours of observation,
observers recorded 2,834
opportunities for HH;
average adherence was
48%. HCWs were most
likely to wash hands after
patient care.
Observers completed 301
hours of observation
(269.5 hours on day shift,
31.5 hours on night shift)
in 365 observation
periods.
2,624 hand washings were
observed.
Researcher(s) Study Observation Observation
Setting/Design Periods Methodology Observers Comments
48
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 3-4. (continued)
Meengs M.R., et al.:
Hand washing
frequency in an
emergency
department. Ann
Emerg Med
23:1307–1312, Jun.
1994.
unit)
• 7-bed surgical
ICU (control
unit)
Objective was to
assess the effect of a
multifaceted
intervention (focus
group sessions,
installation of
automated sinks,
feedback to staff on
HH behaviors) on
influencing HH
behaviors.
Emergency
department of a
large tertiary care
private teaching
hospital in Indiana
over a four-week
period.
• Sinks converted
to fully
sequenced mode;
and
• Two-month post-
intervention
period.
Observations were
done on day and
night shifts.
Patient contacts and
activities for each
emergency
department staff
member (nurses,
resident physicians,
faculty), were
recorded during
three-hour
observation periods.
randomly selected
sinks on both the
experimental and
control units:
• Baseline;
• Phases 2 through
4: One week after
incremental
automation; and
• Post-intervention.
Data were collected
during day and
evening shifts, both
weekday and
weekend.
Observations were
overt but under the
guise of being a
“time-motion” study,
with the data collec-
tion sheet coded so as
not to include any
words suggesting HH
was being observed.
All subjects con-
sented to participate
but their identities
were kept anony-
mous. Three variables
(staff level of training,
years of clinical expe-
rience, and type of
contact with patient
[clean, dirty, gloved])
were examined for
adherence to HH
practices.
consisted of a
minimum of 10
hand washings
with 100% agree-
ment on the
indications for
hand washing.
Observer was a
student in a summer
research program;
details of prepara-
tion/training for the
role of observer in
the study are not
described.
A total of 132 HH
episodes were observed in
35 emergency department
staff and 409 total patient
contacts, for an overall
adherence rate of 32.3%.
Differences were noted
between staff:
• Nurses performed HH
more often than faculty
or residents.
• HH frequency did not
seem to be related to
years of clinical
experience.
• HH was done more
often after dirty or
gloved contacts than
clean contacts.
Researcher(s) Study Observation Observation
Setting/Design Periods Methodology Observers Comments
49
Observing Adherence to Hand Hygiene Guidelines
Appendix 3-5.
Sampling Approaches
As described by Lloyd, there are two basic approaches to
sampling: probability and non-probability.
1
Probability
sampling requires that there be a fixed probability of selecting
any single element (n
i
) from a known population of size n and
that the selection of items from the population is determined
by a random mechanism. Probability sampling is required if
you want to get a truly representative sample of a population.
Probability sampling techniques include simple random
sampling, stratified random sampling, and stratified
proportional random sampling:
• Simple random sampling. One way to assess staff adherence
to hand hygiene guidelines is to obtain a simple random
sample. You can do this by developing a master list of all
staff within the population of interest (this could be a
single unit or the entire organization). Then you select the
staff members you will observe by using a random
selection method, such as selecting every 10th person or
using a random number table. If you decide to select your
sample by using systematic intervals (for example, every
10th person), it is important that you pick your starting
point randomly. It is easier to use this sampling approach
in small units (such as an intensive care unit) than
organizationwide. One variation of this approach to
consider is randomly selecting units or locations to be
observed, rather than people, from a master list.
• Stratified random sampling. Stratified random sampling
involves grouping the population into relatively
homogenous categories before the sample is drawn and
then applying the random selection process within each
level of stratification. For example, if you have a master list
of all clinical staff providing care in the intensive care unit,
you can separate staff on the list by discipline (physician,
nurse, others) and then randomly select staff within each
discipline.
• Stratified proportional random sampling. Stratified
proportional random sampling requires that the proportion
that each stratum represented in the population is
replicated in the sample. For example, you would need to
determine the proportion of staff providing care in the
intensive care unit represented by each discipline and then
select a stratified sample that would accurately represent
the relative proportions of all nurses, physicians, and other
staff involved in care in that intensive care unit.
You can use non-probability sampling techniques when
you are not concerned about generalizing to a larger
population.
1
This approach is often used when focusing on
high-risk areas or on units where an intervention is targeted.
2
It involves selecting a sample that you believe is typical of the
population of interest. Three common forms of non-
probability sampling are convenience sampling, quota
sampling, and judgment sampling:
• Convenience sampling. Convenience sampling is the most
commonly used approach to selecting persons or areas to
measure. It is often used when there are very limited
resources for data collection. To select a convenience
sample, you simply choose staff members or areas of the
organization that are readily accessible and available; hence,
they are “convenient” to study.
• Quota sampling. Quota sampling involves identifying, in
advance, a matrix that describes how many instances of a
certain characteristic you want to account for and then
collecting data until you reach that number of observations
for each characteristic. For example, you might decide that
you want to have observations on at least 100 different
staff members each month, and you want the distribution
of staff members to be 50% nursing, 30% physician, and
20% other. In this scenario, you would observe 50 nurses,
30 physicians, and 20 staff members from other
disciplines.
• Judgment sampling. When using a judgment sampling
approach, the data collector determines who should be
sampled based on the data collector’s expert knowledge of
the subject and what or who the collector believes is most
important to measure. Judgment sampling is most useful
when you want to isolate and study individuals or a
population exhibiting specific characteristics, knowledge,
or activity. You should consider this approach when you
have reason to believe certain groups or areas have
particularly problematic hand hygiene practices.
REFERENCES
1. Lloyd R.C.: The search for a few good indicators. In Ransom
S.C., Joshi M.S., Nash D.N. (eds.): The Healthcare Quality
Book: Vision Strategy and Tools. Chicago: Health Administration
Press, 2005, pp. 103–110.
2. Donabedian A.: Quality of care. JAMA 260(12):1743–1748,
1988.
50
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 3-6.
Examples of Research Articles That Found Evidence of the Hawthorne Effect
Authors/Article
Kohli E., et al.: The Effect of
Recognized Observers on
Measurement of Hand
Hygiene Compliance in
High and Low Performing
Inpatient Units (abstract).
Orlando, FL: Annual
Meeting of the Society for
Healthcare Epidemiology of
America, 2008.
Gould D.J., et al.: Measuring
hand washing performance
in health service audits and
research studies. J Hosp
Infect 66:109–115, Jun.
2007.
Whitby M., McLaws M.L.:
Methodological difficulties in
hand hygiene research.
J Hosp Infect 67:194–195,
Oct. 2007.
Eckmanns T., et al.: Hand
rub consumption and hand
hygiene compliance are not
indicators of pathogen
transmission in intensive care
units. J Hosp Infect
63:406–411, Aug. 2006.
Description
Researchers tested the impact of known and
unknown observers on hand hygiene (HH)
adherence rates in health care workers
(HCWs) at a 382-bed academic medical
center in Lebanon, New Hampshire.
Observational data on HCW HH practices
collected in 2006 by three infection
preventionists (IPs) who were well known to
staff, was compared to data collected in April
and May 2007 by a student, who was not
known to staff. The student conducted
observations in three specifically selected
units: one with historically high HH
adherence (unit A, > 90%), one with poor
adherence (unit B, average of 45%), and one
with recently improved adherence (< 50% to
60%).
In this review article, the authors report that
half of the 42 observational studies considered
the possible effect of direct observation on
HCW adherence rates.
In this letter to the editor, the authors
comment on the complexity of human
behavior in investigating HH adherence in
HCWs.
The study was conducted in five intensive care
units (ICUs) at two university hospitals. Two
observation studies were performed as part of
a more comprehensive study. One observation
period was done without advance notice to
staff, and one was done after prior
notification. Each observational study
consisted of 10 separate observation periods of
120 minutes each.
Findings
Unit A and C both had statistically significant
higher HH adherence rates when the IPs con-
ducted the observations (p = 0.003 and 0.01
respectively). Unit B also had a slightly higher
HH adherence rate when observed by the IPs,
but the rate was not significant (p = 0.3). The
researchers concluded that the use of unrecog-
nized observers may be important in verifying
high performance but is probably unnecessary
in documenting poor performance.
The most frequently used method to try to
avoid the Hawthorne effect was to do observa-
tions covertly. The authors reported that some
organizations are intentionally promoting the
Hawthorne effect to increase adherence, thus
artificially inflating adherence rates and
thereby providing incomplete or misleading
information regarding HCW adherence.
The authors believe the elective component of
HH behavior will react to the Hawthorne
effect, while the inherent component that has
been ingrained since childhood will not be so
affected.
A total of 2,808 HH observations were made.
During the unannounced observation period,
overall adherence was 29%, compared to 45%
in the period with prior notification.
51
Observing Adherence to Hand Hygiene Guidelines
Appendix 3-6. (continued)
Pittet D., et al.: Hand
hygiene among physicians:
Performance, beliefs, and
perceptions.
Ann Intern Med 141:1–8,
Jul. 6, 2004.
Bittner M.J., et al.: Limited
impact of sustained simple
feedback based on soap and
paper towel consumption on
the frequency of hand
washing in an adult intensive
care unit. Infect Control
Hosp Epidemiol
23:120–126, Mar. 2002.
Pittet D., et al.: Effectiveness
of a hospital-wide programme
to improve compliance with
hand hygiene. Lancet
356:1307–1312, Oct. 14,
2000. Errata in Lancet
356:2196, Dec. 23–30, 2000.
Tibballs J.: Teaching hospital
medical staff to handwash.
Med J Aust 164:395–398,
Apr. 1, 1996.
Researchers studied 163 physicians’ adherence
to HH in hospital wards during routine
patient care throughout a large teaching
hospital. At the end of the observation period,
the observer asked the physicians whether they
realized they were being observed.
This prospective study included observations
of staff hand washing in two ICUs in a
Veterans Affairs Medical Center. Actual
counted hand washing episodes (CHWEs) at
each sink were recorded by observers for four-
hour intervals in two ICUs during baseline
and follow-up periods. Observers also weighed
soap and towels at each sink at the beginning
and end of each four-hour session. Using a
regression model that used changes in the
weight of the soap and towels, the observers
calculated estimated hand washing episodes
(EHWEs) that corresponded to the changes in
soap and towel weight. Between the baseline
and follow-up periods, no observers were
present, but EHWEs were still calculated.
More than 20,000 observations of HH
opportunities were documented by the
researchers in a large acute care teaching
hospital before and during implementation of
a HH program.
This was a prospective study of hand washing
by 61 ICU medical staff and visiting medical
staff before and after patient contact in a
pediatric ICU in a tertiary hospital. Baseline
observations were done unobtrusively,
followed by five weeks of overt observation
with advance written notice; next, overt
observation with feedback was done for four
weeks; seven weeks after that, more
unobtrusive observations were done for five
weeks.
Adherence was higher (61%, n = 117) when
physicians were aware that they were being
observed than when they were not aware that
they were being observed (44%, n = 46).
When the researchers compared EHWEs
when observers were present with the EHWEs
when observers were absent, higher EHWEs
were noted when observers were present.
While the campaign produced a sustained
improvement in HH adherence, the authors
recognized the possible roles of observation
bias and Hawthorne effect in their study, even
though their observations were as unobtrusive
as possible.
Baseline HH rates of the 939 patient contacts
observed before and after contact were 12.4%
and 10.6%, respectively. During overt obser-
vation, these rates increased and leveled off at
32.7% and 33.3%. These rates increased
further when feedback on performance was
provided (68.3% before, 64.8% after), but
rates during the last unobtrusive observation
period fell back to 54.6% before and 54.9%
after patient contact.
Authors/Article Description Findings
Measuring product use involves calculating the volume,
quantity, or frequency of using such products as alcohol-
based hand rub (liquid, gel, or foam), liquid soap, and
paper towels or gloves (that is, the number of boxes ordered
or distributed)
Product measurement is considered an indirect
approach to assessing adherence to hand hygiene guidelines
and the frequency of hand hygiene performance.
1,2
As a
result, researchers have found varying degrees of agreement
when comparing hand hygiene adherence rates derived
from product use calculations versus those derived through
the observation method (see Appendix 4-1). As you read
through this chapter, therefore, it is important to contem-
plate the use of multiple measurement methods as a way to
address the strengths and limitations associated with each
measurement approach.
STRENGTHS AND LIMITATIONS OF THE
PRODUCT MEASUREMENT METHOD
Strengths of Measuring Product Use
Measuring product use has several advantages:
• It is less resource intensive, less expensive, and
therefore more efficient than the observation method
of hand hygiene measurement.
• It can be done either manually or electronically.
• It allows organizationwide trends to be tracked over
time.
• It is unobtrusive and reduces sampling bias and the
Hawthorne effect, which are both common with
observation.
3,4
• Product use can be measured across all shifts, 24 hours
a day, 7 days a week.
• It usually requires minimal staff training.
• It can be done in many different health care settings.
Some studies have reported that product measurement
is more sensitive to changes in hand hygiene behavior than
is observation. Consider the following examples:
• During a performance improvement project to
implement the Centers for Disease Control and
Prevention’s (CDC’s) 2002 hand hygiene guideline in
their organization, Aragon et al. described how they
educated staff on the benefits of hand hygiene,
stressing the effectiveness of the alcohol-based hand
rubs over hand washing, and increased the availability
of the product on the units.
5
Alcohol foam use,
tracked by the infection control department, doubled
despite only a modest improvement in hand hygiene
practice, based on observation in the first six months
of the project.
• An Australian study compared direct observation with
product measurement to determine the relative
accuracy of these methods, as part of a hand hygiene
intervention.
3
The authors noted that consumption of
alcohol-based hand rub increased significantly, while
direct observations showed no improvement in hand
hygiene performance. The authors concluded that
direct observation captures only a fraction of the total
hand hygiene episodes practiced and that observation
is neither a representative nor accurate measure of
53
chapter 4
MEASURING PRODUCT USE
hand hygiene performance. Haas suggested that, in
both of these studies, hand hygiene observations
inaccurately reflect total hand hygiene behavior
because the sample selected underrepresented the
populations studied.
1
Two other researchers found an association between
hand hygiene interventions to improve adherence and
increased use of product:
• Pittet et al. measured product use as part of a hand
hygiene intervention.
6,7
They found a progressive
improvement in hand hygiene during a hand hygiene
campaign between 1994 and 1997, based on more
than 20,000 observed hand hygiene opportunities.
Ongoing measurement revealed a statistically
significant increase in the use of alcohol-based hand
rub per 1,000 patient days between 1993 and 2001.
• McGuckin and colleagues described how they assessed
health care workers’ adherence to hand hygiene
guidelines during a patient empowerment intervention
in a hospital in the United Kingdom.
8
Patients who
agreed to participate in the intervention asked health
care workers who were about to have contact with
them “Did you wash your hands?”. The authors
assessed adherence by measuring the volume of soap
and alcohol-based hand rub used per bed day both
before and after the intervention, with a 50% increase
in the amount of products used after the intervention.
Limitations of Measuring Product Use
Measuring product use has some limitations:
• The validity of this approach has not been well
established.
2
• Because product measurement is not tied directly to
opportunities for hand hygiene, measuring product
use does not reveal whether health care workers
perform hand hygiene when indicated.
1
• Product use does not provide any information about
when and why hand hygiene does not occur. van de
Mortel notes that product use does not show who is
and who is not practicing hand hygiene, or how well
they are practicing it.
3
• Measuring product use can be inaccurate and produce
misleading results. Inaccuracy in measurement is
frequently caused by the following:
— Wasting or spillage of product, discarding of
containers before they are empty, or changes in
volume dispensed.
— Inability to separate product used by patients and
families from product used by staff. The inability to
distinguish who is using the product may results in
the overestimation of health care worker adherence
to hand hygiene guidelines.
1
— “Gaming” (deliberate or intentional inflation of
measurements) of the process by using extra
product.
9
— Ordering of more product than is needed or
anticipated to be needed.
10
“Borrowing” of product
between wards.
10
— Failure to adjust adherence rates for workload or
patient case mix.
1,2
— Evaluation of product use based on product
purchase during a specified time period. (The
amount purchased may differ from the amount
used due to shelf life.)
— Failure to account for pocket bottles.
COMPONENTS OF THE MEASUREMENT
METHOD
There are two primary ways to measure product use. The
first is to measure the amount of a product that is used, and
the second is to measure the frequency with which the
product is used.
Measuring the Amount of Product Used
You can weigh or otherwise measure products such as soap,
alcohol-based hand rub, and paper towels. For example, you
can weigh or measure the height of soap or alcohol-based
hand rub remaining in the dispenser, or you can measure
the height of a stack of paper towels from one period of
time to another. An easier approach might be to count the
number of soap or alcohol-based hand rub containers, the
stacks of paper towels placed on a unit, or the number of
empty containers removed from the unit. When you have
settled upon a specific measurement methodology, data can
be collected consistently across the organization. This
approach allows you to calculate the amount of product
used at the specific unit, department, or organizational
54
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
level. Information on product use can also be collected for
the entire health care organization by looking at purchasing
or inventory data. You can report data on the quantity of
products ordered or supplied throughout the organization
at regular intervals (e.g., quarterly, annually). Of course, one
drawback to measuring product use though purchasing or
inventory data is that the number of hand hygiene oppor-
tunities varies by unit or department (see Appendix 3-2 in
Chapter 3 for more information).
Text Box 4-1 describes how one organization measured
product use at the unit or departmental level. Text Box 4-2
describes how two organizations measured product use at
the organizational level.
Measuring the Frequency of Product Use
An alternative to measuring the amount of hand hygiene
product used is to use automated tools—including elec-
tronic counting devices and electronic monitoring
systems—to measure how frequently it is used.
Electronic Counting Devices
Several researchers have had experience with electronic
counting devices in soap or alcohol-based hand rub dis-
pensers:
• Larson et al. compared direct observation with
electronic counting devices in dispensers.
11
The
authors concluded that using electronic counters may
be a practical way of monitoring hand hygiene
adherence at the unit level. Because counters can be
expensive, the authors suggest using a few counters
and extrapolating the results to dispensers without
counters.
• In another study, Larson and colleagues assessed the
impact of an intervention to change an organization’s
culture in relation to the frequency of hand hygiene
performance by health care workers, as measured by
counting devices inserted in soap dispensers on four
critical care units.
12
Each time soap was dispensed, the
device recorded one count. A data collector routinely
55
Measuring Product Use
Text Box 4-1.
Measuring at the Unit or Department Level
Shriners Hospital for Children in Erie, Pennsylvania,
developed a method for estimating hand hygiene adherence
based on the amount of hand hygiene product used in its
outpatient clinic. In late summer 2007, the hospital began to
collect the following data to calculate hand hygiene adherence:
• Quantity of hand hygiene liquid (total milliliters) supplied
to the clinic per month
• Quantity of hand hygiene liquid remaining in the
dispensers at the end of the month (dispensers were
marked at the level of remaining product at the end of the
month)
• Number of patient visits per month
• Observations of all staff who entered each treatment room
during patient visits to the clinic over a two-day period
The hospital subtracted the amount of product left in
dispensers at the end of each month from the amount of
product supplied to the clinic per month to calculate the total
product volume used. From observations, the hospital
established that the average patient had 15 staff entries during
a visit.
Shriners used the amount of hand hygiene liquid (total
milliliters) used per month divided by the average amount of
product dispensed (in milliliters) for each hand hygiene
episode to determine how many hand hygiene episodes took
place; this was then compared to the number of patient visits
per month and multiplied by 15 (the average number of staff
entries that should have resulted in at least one hand hygiene
episode) to determine the minimum number of hand hygiene
episodes that should have taken place. To calculate the hand
hygiene adherence rate, Shriners divided the actual hand
hygiene episodes by the calculated expected hand hygiene
episodes that were based on patient volume and observational
process studies. The resulting adherence rate was trended over
time and fed back to the clinic. Only a short time after the
initiative was put into place, the hospital began to see an
increase in hand hygiene activity by tracking product usage. A
follow-up observational study was planned in order to
determine whether hand hygiene practice had improved.
recorded readings from all counters and reset each one
after the reading.
• Researchers at the Hospital of Saint Raphael in New
Haven, Connecticut, placed electronic devices in
alcohol-based hand rub dispensers on a general
medical unit and an intensive care unit. The devices
recorded each time a dispenser was accessed; data were
periodically downloaded via a handheld data transfer
unit and then transferred to a secure Web site for
analysis. The researchers were able to determine the
number of hand hygiene episodes per patient day for
each unit, map the location of each device to see
which dispensers had the highest and lowest usage,
and determine average uses per hour per dispenser by
time of day. They felt this method permitted
evaluation of the impact of hand hygiene
interventions and was useful for studying the effects of
dispenser location on product usage patterns.
13
• A recent study of the correlation between product
measurement and observation used electronic
counting devices in dispensers. Researchers at Yale-
New Haven Hospital in New Haven, Connecticut,
placed electronic counters in each hand sanitizer
dispenser located in two general medical units and a
medical intensive care unit. The counters recorded
dispenser lever depressions and electronically
registered dispensers’ location and the date and time
of every event. Observations of hand hygiene
opportunities per hour were performed in each study
unit to determine the optimal number of hand
hygiene episodes per patient bed day.
14
• The Veterans Affairs Medical Center in Omaha,
Nebraska, used counting devices installed in soap and
alcohol-based hand rub dispensers on individual units.
The devices counted each episode in which the
dispenser was pressed. Each week, all the counts were
read and summed; then the previous week’s sum was
subtracted from the current week’s sum. The result
was the total number of times the soap and alcohol-
based hand rub were dispensed in the units during the
previous week. The organization then divided these
episodes by the number of patient care days.
4
• The Dana Farber Cancer institute in Boston uses a
touch-free dispenser and a hand hygiene monitoring
system that is not linked to the individual who uses
the sink. This system has a faucet with a
programmable water suspension/lather time. Daily
and total wash counts are displayed on an LCD,
which links to a network and generates activity reports
indicating the number of correctly completed hand
hygiene episodes recorded at that dispenser.
56
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Text Box 4-2.
Measuring at the Organizational Level
As part of its efforts to increase hand hygiene among hospital
employees, Brookhaven Memorial Hospital Medical Center in
Patchogue, New York, placed alcohol-based hand rub
dispensers in all patient care areas throughout the organization
in October 2003. The hospital has also been keeping track of
the total annual purchases of product for the organization as a
whole, noting that the amount purchased doubled between
2001 and 2005.
Aragon et al. described how, as part of an improvement project
while implementing evidence-based guidelines for hand
hygiene, they increased the availability of alcohol-based hand
rub products in their hospital.
5
The infection control
department tracked the number of cans of alcohol-based hand
rub the organization ordered and consumed per 1,000 patient
days. Six months after the start of the improvement project,
alcohol-based hand rub consumption doubled from the pre-
project baseline, and it remained high 9 and 12 months
post-implementation.
There are some drawbacks to using electronic devices to
count or collect information about hand hygiene perform-
ance. Multiple hits at a dispenser per person per hand
hygiene event may artificially inflate the statistics about
product use. Larson et al. counteracted this possible effect
by using an auto-delay circuit and an automatic shutoff if
five dispensing cycles occurred within 15 seconds.
11
Other
limitations of electronic counting devices include the fol-
lowing:
• They are susceptible to “gaming” by an individual
who repeatedly manipulates the dispenser.
• They are expensive.
• Batteries and counters can occasionally fail.
• Time is needed to read the counters and record the
data.
• The dispensers can be damaged, stolen, or subject to
limited access.
• A decreased amount of product may be dispensed as a
dispenser ages.
Electronic Monitoring Systems
Electronic monitoring systems are designed to track
product amount or frequency of use relative to specific
events. They sometimes emit sounds that serve as reminders
for health care workers to perform hand hygiene. Some
systems track and record hand hygiene actions by individ-
ual health care workers. These technologically advanced
devices are relatively new and expensive to purchase, and
they have not been proven to result in sustained improve-
ment in hand hygiene.
11,15
Examples of electronic systems include the following:
• A tracking system that can record use by individual
health care workers has been developed. Dartmouth-
Hitchcock Medical Center in Lebanon, New
Hampshire, began testing the system in late 2007.
The dispenser, which is worn at the waist or from a
lanyard and can be operated with one hand,
electronically records each time the dispenser is used.
The data are downloaded into a computer and
summarized into hand hygiene episodes for each hour
worked, or into “average hourly episodes” (AHEs) for
a shift, week, month, quarter, or year. AHEs can also
be represented in terms of patient days. The system
provides individual health care worker feedback
reports that compare hand hygiene episode rates with
position- and setting-based goals. The system also
includes an optional audio reminder system that,
when activated, produces a soft white-noise sound
each time the hand rub is dispensed; if the dispenser is
not used again for a given number of preset delay
minutes, it will emit the reminder sound. The audio
system is intended to be used for the first few days a
health care worker is wearing the dispenser, as a
reminder to help establish use of the dispenser.
• Researchers at a Canadian rehabilitation hospital have
developed a system that uses infrared sensors over a
patient’s bed to detect whether health care workers
have washed their hands or used alcohol-based hand
rub. Health care workers wear a device that beeps if
hand hygiene is not performed before or after patient
care. The system also records the last time hand
hygiene was performed via the alcohol-based hand rub
dispenser that the health care worker wears and is
electronically tied to the system. The system is
expected to be available by 2010.
16
• Venkatesh et al. studied the utility of using electronic
alerts to enhance hand hygiene adherence.
17
They
placed electronic monitoring devices in alcohol-based
hand rub dispensers, which also had motion detectors,
outside 12 patient room entrances on one unit; they
defined a hand hygiene opportunity as an entry to or
an exit from one of the 12 rooms. If hand hygiene did
not occur on entry or exit, the device produced a
flashing light and a series of three simultaneous beeps,
along with a prerecorded voice prompt that said,
“Please wash your hands.” The system recorded each
hand hygiene opportunity and each time a health care
worker dispensed hand rub in conjunction with the
opportunity. The authors concluded that the
electronic devices not only effectively monitored hand
hygiene adherence but also facilitated improved
57
Measuring Product Use
adherence from a baseline of about 36% to about
70% after the electronic monitoring devices were in
use.
• An automated system electronically calculates soap
and alcohol-based hand rub use by detecting when a
soap or sanitizer dispenser lever is pressed. Each such
action is transmitted wirelessly to a nearby computer,
which then automatically sums the amount of soap
and alcohol-based hand rub used by room, unit, shift,
and day. Dividing total soap and sanitizer use per day
by the patient census yields hand hygiene events per
patient per day. Swoboda and colleagues describe how
they used this system’s motion detectors at the
threshold of each patient room to monitor everyone
who entered and exited the room, along with
electronic and computer systems to monitor the use of
toilets, sinks, and alcohol-based hand rub dispensers.
18
By setting time parameters, the computer system
attributed hand hygiene performance or the lack
thereof with each entry and exit. The system also
included optional prerecorded voice prompts that
automatically played if a health care worker did not
perform hand hygiene prior to exiting a room or
within 10 seconds of leaving the room. However,
because the system could not determine who entered a
patient room and whether hand hygiene was
indicated, the denominator was much larger than the
numerator, resulting in a low adherence rate.
ESTIMATING ADHERENCE RATES WITH
PRODUCT USE DATA
As an indirect measure of hand hygiene adherence, product
use measurements cannot be used to directly calculate
adherence rates, but they can be used to estimate them.
Such estimates are most useful when they can be viewed
within the context of a broader measurement strategy (that
is, the multiple methods approach).
Customizing Calculations to Specific Units
Because the number of opportunities for hand hygiene
varies widely according to the setting and patient popula-
tion, it is important to determine a realistic number of
expected opportunities based on the unit you are studying.
Larson et al. suggest that monitoring hand hygiene
product use can indicate of the number of hand hygiene
episodes.
11
They propose the method for calculating a unit-
specific hand hygiene adherence rate summarized in Table
4-1.
Tools and Systems for Aggregating and
Comparing Information
The Veterans Administration National Center for Patient
Safety makes spreadsheets available online
(http://www.va.gov/ncps/SafetyTopics/HandHygiene/inde
x.html) for calculating the rate of alcohol-based hand rub
used per 100 patient days and per 1,000 patient days. After
you identify which alcohol-based hand rub is being used in
your facility, you can select the appropriate spreadsheet. (If
your organization uses alcohol-based hand rub containers
different in size from the choices on the spreadsheet, you
can adapt the form by changing the grams in the “Grams
per Can” column). To track the data, each month you enter
in the spreadsheet the number of cans or containers used
and the number of patient days of care provided in the area
in which the cans or containers were used.
Text Box 4-3 describes two hospitals that use a system for
product measurement that has benchmarking capabilities.
58
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
59
Measuring Product Use
Table 4-1.
Method for Calculating a Unit-Specific Adherence Rate
Parameter
Number of indications for
hand hygiene
Number of actual episodes
of hand hygiene
Hand hygiene adherence
rate
Ongoing monitoring
Method of Assessment
1. Directly observe personnel long enough to observe
approximately 200 indications.
2. Divide the total number of indications by the total
time observed to obtain a mean number of
indications for hand hygiene per hour.
3. Multiply the value obtained in step 2 by 24 to get
the mean number of indications per day.
4. Obtain the patient census for the period the
observations were made.
5. Calculate mean number of indications for hand
hygiene per day per patient by dividing mean
number of indications per day by the census value.
1. Obtain data on volume of hand hygiene products
(soap and alcohol) used per month for the unit.
1
2. Divide the total volume used by the amount of
product dispensed with each hit.
2
1. Compute number of indications per month by
multiplying indications for hand hygiene per day
per patient by the number of days in the month by
the mean monthly patient census.
2. Obtain a hand hygiene adherence rate by dividing
the total number of hits by the total number of
indications for that month.
1. Repeat baseline observations if evidence indicates
that patterns of hand hygiene have changed or if a
hand hygiene intervention is planned.
Example
200 indications for hand hygiene were
observed during a period of 5 hours
200 / 5 = 40 indications per hour
40 x 24 = 960 indications per day
Patient census for day of observation
was 30
960 / 30 = 32 indications for hand
hygiene per day per patient
12,000 mL of product used per
month
12,000 mL / 1.5 mL per hit = 8,000
total hits/month
32 indications x 30 days x 32 mean
monthly census = 30,720 indications
in that month
8,000/30,720 = 26.0% adherence rate
Not applicable
1. This step will require coordination with the purchasing department
2. The amount of product dispensed with each hit may vary according to the type of product or dispenser
Source: Larson E.L., Albrecht S., O’Keefe M.: Hand hygiene behavior in a pediatric emergency department and a pediatric intensive
care unit: Comparison of use of 2 dispenser systems. Am J Crit Care 14:304–310 (table is located on p.308), Jul. 2005. Used with
permission.
KEY POINTS, CHAPTER 4
• Measuring product use is an indirect
approach to measuring hand hygiene
adherence, the validity of which has not been
well established.
• Because the number of opportunities for hand
hygiene varies widely according to the setting
and patient population, it is important to
calculate adherence rates using realistic
numbers of expected opportunities that are
appropriate to the unit.
• Technological solutions ease data collection
but do not necessarily overcome the
limitations of measuring product.
REFERENCES
1. Haas J.P., Larson E.L.: Measurement of compliance with hand
hygiene. J Hosp Infect 66:6–14, May 2007.
2. World Health Organization (WHO): WHO Guidelines on Hand
Hygiene in Health Care (Advanced Draft): A Summary. Geneva,
Switzerland: WHO, 2006.
3. van de Mortel T., Murgo M.: An examination of covert
observation and solution audit as tools to measure the success of
hand hygiene interventions. Am J Infect Control 34(3):95–99,
2006.
4. Bittner M., VA Medical Center, Omaha, NE, personal
communication, Nov. 8, 2007.
5. Aragon D., Sole M.L., Brown S.: Outcomes of an infection
prevention project focusing on hand hygiene and isolation
practices. AACN Clinical Issues 16:121–132, Apr.–Jun. 2005.
6. Pittet D., et al.: Effectiveness of a hospital-wide programme to
improve compliance with hand hygiene. Lancet 356:1307–1312,
Oct. 14, 2000. Errata in Lancet 356:2196, Dec. 23–30, 2000.
7. Pittet D., et al.: Cost implications of successful hand hygiene
promotion. Infect Control Hosp Epidemiol 25:264–266, Mar. 2004.
8. McGuckin M., et al.: Evaluation of a patient-empowering hand
hygiene programme in the U.K. J Hosp Infect 48(3):222–227,
2001.
9. Bittner M.J.: Surveillance of handwashing episodes in adult
intensive-care units by measuring an index of soap and paper
towel consumption. Clinical Performance and Quality Health Care
6:179–182, Oct./Nov./Dec. 1998.
10. Gould D.J., et al.: Measuring handwashing performance in health
service audits and research studies. J Hosp Infect 66:109–115,
2007.
11. Larson E.L., Albrecht S., O’Keefe M.: Hand hygiene behavior in a
pediatric emergency department and a pediatric intensive care
unit: Comparison of use of 2 dispenser systems. Am J Crit Care
14:304–310, Jul. 2005.
12. Larson E.L., et al.: An organizational climate intervention
60
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Text Box 4-3.
Measuring Product Use with Comparative Reports from a Measurement System
Many facilities with hand hygiene adherence monitoring
programs use a product measurement system that has
benchmarking capabilities. The system provides health care
workers and patients with educational tools and includes a
data measurement component.
Two eastern U.S. hospitals have used the services of a
measurement system for calculating and comparing adherence
rates. This measurement system, developed in 2003, estimates
hand hygiene episodes per bed day based on an average
amount of product used (1.7 mL soap and alcohol-based hand
rub per hand hygiene episode) by unit type. As with all the
other participants in this system, Eastern Maine Medical
Center in Bangor, Maine, and Caritas Norwood Hospital in
Norwood, Massachusetts, submitted data each month and
received monthly hand hygiene adherence reports that
included benchmarking by unit type and hospital size.
Housekeeping staff collected and counted empty soap and
alcohol-based hand rub product containers; the monthly total
of each, by unit, was forwarded to the individual or
department that prepared the data submission forms that went
to the measurement system. Initially, both organizations
collected baseline product usage data for six weeks for specific
units. (The measurement system also permits organizationwide
aggregate data collection if unit-specific product usage cannot
be determined.) When the baseline usage information was
complete, the organizations implemented their intervention
program, which included patient empowerment in asking
health care workers if they had washed or sanitized their hands
before providing care. Following implementation of the
intervention, the organizations began the measurement and
benchmarking portion of the program. The methodology used
for the benchmarking is a linear regression model that uses
prediction intervals calculated at the 10th and 90th percentiles.
Graphs with monthly data points and a table are produced for
each unit. More information about the methodology and
sample graphs are available at http://www.hhreports.com.
associated with increased handwashing and decreased nosocomial
infections. Behav Med 26:1–14, Spring 2000.
13. Boyce J.M., Cooper T., Dolan M.: Evaluation of an Electronic
Device for Real-time Measurement of Use of ABHR (abstract).
Society for Healthcare Epidemiology of American annual scientific
meeting, Orlando, FL, April, 2008.
14. Torres-Viera C., Dolan M., Dembry L.-M.: Correlation Between
Direct Observation of Hand Hygiene Compliance and Electronically
Monitored Use of Hand Sanitizer (abstract). Society for Healthcare
Epidemiology of American annual scientific meeting, Orlando,
FL, April, 2008.
15. Wurtz R., Moye G., Jovanovic B.: Handwashing machines,
handwashing compliance, and potential for cross-contamination.
Am J Infect Control 22:228–230, Aug. 1994.
16. System prompts hospital staff to wash hands in bid to cut patient
infections. CBC News, Mar. 3, 2008.
17. Venkatesh A.K., et al.: Use of electronic alerts to enhance hand
hygiene compliance and decrease transmission of vancomycin-
resistant Enterococcus in a hematology unit. Am J Infect Control
36:199–205, Apr. 2008.
18. Swoboda S.M., et al.: Electronic monitoring and voice prompts
improve hand hygiene and decrease nosocomial infections in an
intermediate care unit. Crit Care Med 32(2):358–363, 2004.
61
Measuring Product Use
Appendix 4-1.
Studies Examining the Association between Product Measurement and Observation
Authors/Article
Torres-Viera C., Dolan M.,
Dembry L.-M.: Correlation
Between Direct Observation
of Hand Hygiene
Compliance and
Electronically Monitored Use
of Hand Sanitizer (abstract).
Society for Healthcare
Epidemiology of American
annual scientific meeting,
Orlando, FL, April, 2008.
Eckmanns T., et al.: Hand
rub consumption and hand
hygiene compliance are not
indicators of pathogen
transmission in intensive care
units. J Hosp Infect
63:406–411, Aug. 2006.
Description of Measurement Method
Electronic counters were installed in alcohol-
based hand rub (ABHR) dispensers in two
general medical units and a medical intensive
care unit (MICU). They recorded dispenser
lever depressions and electronically recorded
the dispenser location, date, and time of each
event. Observations of hand hygiene (HH)
opportunities per hour were conducted in
each study unit to determine the optimal
number of HH episodes per patient bed day
during the two-month study period.
The authors performed two HH observation
studies (10 months apart); each observation
period consisted of 10 separate observation
periods (120 minutes each), to capture staff
HH activities. Data were compared from
2,808 observations of HH opportunities
across five intensive care units (ICUs) in the
university hospitals with ABHR consumption
data obtained from the pharmacy. ABHR
consumption was calculated per 1,000 patient
days. In addition, the authors genotyped all
Description of Findings
During the study period, mean events per
month were 21,432 (MICU), 20,872 (Unit
A), and 29,317 (Unit B), which corresponded
to 43.8, 18.9, and 22.6 HH events per bed
day, respectively. There was no statistically sig-
nificant difference in events per bed day when
each unit was evaluated in terms of night and
weekend vs. day and weekday dispenser use.
Observed HH adherence as measured by
direct observation was 88%, 80%, and 70%,
for MICU, Unit A, and Unit B, respectively.
Calculated HH adherence by electronically
determined events per bed day was 38%,
14%, and 15%, respectively. Rates of observed
HH adherence were much higher than rates as
measured by electronic surveillance and calcu-
lated based on the optimal average events per
bed day.
Correlation between ABHR consumption and
HH adherence was 0.87 (p = 0.05).
More than 30,000 specimens were received by
the microbiology laboratory, and 141 trans-
mission events were identified. Forty-one
(29%) of the transmissions were related to
health care–associated infections. The inci-
dence of health care–associated infections was
found to be a relatively good indicator for the
identification of pathogen transmission, but
there was no correlation between the
62
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 4-1. (continued)
Sohn-Tuma S., et al.: Hand
hygiene product
consumption rates: What
does it tell us about
compliance? (abstract).
Society for Healthcare
Epidemiology of America
annual scientific meeting,
Chicago, March, 2006.
Bittner M.J., Rich E.C.,
Arnold W.H.: Limited
impact of sustained simple
feedback based on soap and
paper towel consumption on
the frequency of hand
washing in an adult intensive
care unit. Infect Control
Hosp Epidemiol
23:120–126, Mar. 2002.
Bittner M.J., Rich E.C.:
Surveillance of handwashing
episodes in adult intensive-
care units by measuring an
index of soap and paper
towel consumption.
Clinical Performance and
Quality Health Care
6:179–182, Oct.–Dec. 1998.
isolates of the most frequent pathogens from
patients hospitalized in two organizations’
ICUs for > 48 hours to identify transmission
episodes. The incidence of transmission was
correlated with HH adherence and health
care–associated infection rates.
Trained observers monitored health care
worker traffic and HH practices over a 17-
month period on six inpatient floors at a
425-bed tertiary care hospital. Purchased
quantities of soap and ABHR were obtained
from the hospital’s General Services
Department.
The researchers used a regression model using
soap and towel weight changes during
observation sessions of actual hand washing
episodes to calculate estimated hand wash
episodes (EHWEs) in the MICU and surgical
intensive care unit (SICU) of a medical center.
They then calculated each unit’s average daily
EHWEs per occupied bed.
Live observations, in four-hour intervals, of
staff HH episodes were done in a MICU and
SICU at a medical center during a six-month
period (divided into baseline and four follow-
up periods). The observer also measured paper
towel height, towel weight, and soap weight at
each sink on all non-holiday weekdays during
the same period of time. Nurse staffing and
the number of occupied beds for each unit
were also recorded.
incidence of transmission episodes and hand
rub consumption or HH adherence.
Overall observed HH adherence in 7,936
opportunities was 23.7%; during the same
period, the estimated adherence using con-
sumption of products was 74.4% assuming 1
dispensing per HH episode or 37.2% assuming
2 dispensings per HH episode. The authors
concluded that volume-based indicators alone
may not accurately reflect HH adherence and
presents difficulties in interpretation.
A strong relationship was found to exist
between actual counted hand washing
episodes and the consumption of soap and
towels, with all correlations significant (p <
.001).
A total of 759 HH episodes were observed
during the study period. Data from baseline
and the four follow-up periods were tested to
determine the relationship between the
counted HH episodes and the consumption of
soap and towels. For both units, stepwise
regression retained changes in the weight of
soap and towels as independent variables (p <
.0001), with R2 = 0.965 (MICU) and 0.981
(SICU).
Authors/Article Description of Measurement Method Description of Findings
“The principal objectives [of a survey] should always be to collect
reliable, valid, and unbiased data from a representative sample,
in a timely manner and within resource constraints.”
1(pg. 2)
Surveying health care workers, patients, and family
members is an indirect method of assessing aspects of
hand hygiene adherence. You can use surveys to gather
information on health care worker perceptions, attitudes,
and practices related to hand hygiene, as well as patients’
and families’ attitudes and perceptions related to the hand
hygiene practices of health care workers. Surveys can be
administered over the telephone, electronically (over a
computer network or via the Internet), on paper (on-site
or via mail) or through in-person interviews and focus
groups. In-person interviews allow you to not only ask
the planned questions but to probe more deeply into an
individual’s responses. Conducting focus groups, which
are essentially guided conversations, can help you elicit
information underlying complex behavior and motiva-
tion and can yield descriptions and insights that are
difficult to capture in individual interviews or other types
of surveys.
2
How you administer a survey depends on considera-
tions such as the number of people you plan to reach, where
they are located, and the complexity of the sample (for
example, all health care workers in a particular region of the
country vs. physicians in one hospital’s intensive care unit).
Each method has advantages and disadvantages, as the
mode of survey administration has been shown to affect
how individuals respond to identical survey questions.
3
For
a more in-depth discussion of survey administration, see
Burroughs et al.,
4
Kellerman et al.,
5
and Rodriguez et al.
6
STRENGTHS AND LIMITATIONS OF USING
SURVEYS
Strengths of Using Surveys
Surveys can measure a range of hand hygiene components
that observation and product measurement alone cannot
measure, including the following:
• Staff knowledge, attitudes, and beliefs
• Health care workers’ perceptions of their own
behavior
• Patient and family satisfaction with staff hand hygiene
• Health care workers’ satisfaction with hand hygiene
products
• Structural issues, such as the availability of hand
hygiene products, product accessibility, and the like
Not only are surveys useful for learning what health
care workers know and think, surveys are useful for uncov-
ering why health care workers adhere (or do not adhere) to
hand hygiene guidelines. For example, if you discover that
health care workers are not adhering to guidelines, a survey
can help you determine the following:
• Whether health care workers are unaware of existing
guidelines
• Whether health care workers are unfamiliar with their
organization’s hand hygiene policies
• Whether health care workers have considered all of a
guideline’s details
63
chapter 5
CONDUCTING SURVEYS
• Whether health care workers have a negative attitude
toward adhering to guidelines, and if so, why
Surveys can be used to address a range of components
and be combined with other methods of measuring hand
hygiene. For example, one study combined the use of ques-
tionnaires and focus groups in order to assess the
effectiveness of a poster campaign to improve the rates of
hand hygiene performance.
7
A well-designed and carefully
administered survey can be used to guide the development
of your organization’s educational programs and initiatives
or to evaluate the effectiveness of your educational efforts
when they are complete.
Limitations of Using Surveys
Surveys have some limitations, which may vary based on
the type of survey being administered. They include the fol-
lowing:
• Surveys to determine hand hygiene adherence can
yield results that are inaccurate, unreliable, or lacking
in validity, as health care workers tend to overestimate
their adherence to hand hygiene guidelines on
surveys.
8
• The validity of the survey depends on how well the
survey was developed and administered. Inadequate
validity testing is common.
8,9
Before using an existing
tool, you should determine whether its validity (does
it adequately reflect the meaning of the concept under
study?) and reliability (do the questions mean the
same thing to every respondent?) have been
established.
• Surveys that ask respondents to remember something
from the past can introduce recall bias. Recall bias can
occur because memories are imperfect and vary based
on individual perception. This makes eliciting accurate
and reliable responses about a past incident or process
difficult.
Before you administer a survey to gather hand hygiene
information, it is important to keep several additional con-
siderations in mind:
• Consider survey bias:
— Will the results accurately represent the
population?
— Will everyone in the survey population have an
equal opportunity to respond?
— What is your desired response rate?
— How much follow-up is needed to obtain that
response rate?
— What might the differences be between survey
responders and nonresponders?
• How readable and understandable are the survey
questions, particularly to non-health care workers?
• How will you manage language or other
communication-related challenges?
• How much time has elapsed between fielding the
survey and the event(s) about which your survey asks?
As is the case with observation and product measurement,
the accuracy of your results also depends on how well the
survey is implemented. A low response rate or a biased sample
can make your survey results less useful because the informa-
tion cannot be generalized to the population you are
interested in studying. A detailed discussion of general
methodological considerations for surveys is beyond the scope
of this monograph. Edgman-Levitan
10
and Krueger
11
are good
texts to consult for more in-depth discussion of these issues.
Finally, it is important to share results with those who
contributed through the survey. Follow-up actions based on
staff recommendations demonstrates that their input is
valued.
COMPONENTS OF HAND HYGIENE THAT
SURVEYS CAN ASSESS
The following sections address the different components of
hand hygiene that surveys can help you assess:
• Staff knowledge
• Staff attitudes and beliefs
• Staff perceptions of their own, or their colleagues’,
behavior
• Structural factors that can facilitate or inhibit staff
hand hygiene performance
64
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
• Patient and family satisfaction with staff performance
• Staff satisfaction with products
• Assessment of staff skin condition
Appendix 5-1 provides examples of surveys that have
been used to address each of these components, along with
the source or developer of the survey and its title.
Staff Knowledge
The Institute for Healthcare Improvement (IHI) recom-
mends periodically surveying staff to assess their knowledge
about key elements of hand hygiene as part of a multidi-
mensional hand hygiene program.
12
If survey results
indicate that staff education about guidelines is needed,
surveys can help you assess the effectiveness of your educa-
tional efforts by tracking changes in staff knowledge over
time. Appendix 5-1 lists examples of tools your organization
can use to assess staff knowledge about hand hygiene guide-
lines and indications.
Staff Attitudes and Beliefs
Staff attitudes and beliefs directly affect hand hygiene
behavior.
13
For example, Pittet et al. conducted a survey to
determine why physician adherence to hand hygiene guide-
lines did not substantially improve after a promotional
campaign, when all other health care workers’ adherence
did.
14
Physicians were given a self-report survey that asked
questions about their attitudes, beliefs, and perceptions
regarding hand hygiene. The researchers found that atti-
tudes and beliefs may explain differences in adherence to
hand hygiene guidelines between physicians and other
health care workers in the same hospital.
14
In another study, Sax et al. conducted a self-report
survey to quantify the different behavioral components of
health care workers’ motivation to perform hand hygiene.
15
The survey revealed that adherence to hand hygiene guide-
lines is driven by peer pressure and the perception of high
self-efficacy rather than by awareness of the impact of hand
hygiene on patient safety. Women, health care workers who
received training in hand hygiene, and those who had been
exposed to a hand hygiene campaign were more likely than
others to adhere to hand hygiene guidelines. Appendix 5-1
lists several survey instruments that assess health care
workers’ attitudes and beliefs related to hand hygiene.
Staff Self-Perceptions of Hand Hygiene
Behavior
How accurate are self-reported surveys of hand hygiene
behavior? One study compared the results of direct observa-
tion for measuring nurses’ hand hygiene performance with
the performance they recorded in their diaries for 22
months.
16
The study measured the following aspects of hand
hygiene behavior:
• The number of times per hour nurses washed their
hands
• The number of times per hour nurses applied alcohol
hand rub
• The number of times per hour nurses applied hand
lotion
• The number of times per hour nurses donned and
removed gloves
• The number of minutes and hours nurses spent
wearing gloves
The two measurement methods yielded different
results, but the researchers were unable to determine which
measurement method was more accurate or less biased,
given the many variables that can affect the results of direct
observation (discussed in detail in Chapter 3).
In another study, researchers compared hand hygiene
practices of health care workers resulting from both direct
observation and their answers to a questionnaire.
17
Physicians reported greater adherence to hand hygiene indi-
cations than observers noted, especially before an invasive
procedure. A 1996 study by Tibballs et al. also found that
physicians tended to overestimate their hand hygiene per-
formance.
18
Nurses reported lower adherence to hand
hygiene indications than observers noted for all technical
procedures. The reverse was true for hand washing before
invasive procedures, but the differences between self-
reported behavior and observed behavior were not
statistically significant. The results of this study indicate an
65
Conducting Surveys
overall consistency between self-reported and observed
hand hygiene behavior practices for nurses.
On the other hand, O’Boyle et al. compared nurses’
adherence to hand hygiene guidelines based on observation
and self-reported adherence in four hospitals.
19
They found
that, on average, the nurses reported greater adherence to
the guidelines than observers noted. Based on their find-
ings, these researchers concluded that the self-report
method for measuring hand hygiene performance is inade-
quate and should not be used.
Other researchers have highlighted the limitations of
using health care workers’ self-report surveys to measure
hand hygiene performance.
9
Although self-report surveys
are inexpensive to administer and may prompt health care
workers to think about their hand hygiene behavior, studies
such as those cited here indicate that their validity for meas-
uring hand hygiene adherence is weak.
Examples of tools that assess self-reported hand hygiene
behavior are listed in Appendix 5-1.
Structural Factors and Considerations
Structural factors and considerations refer to the physical
availability and accessibility of hand hygiene products.
Some examples of these factors and considerations are
whether soap and alcohol-based hand rub are readily avail-
able, whether dispensers and sinks are in good working
order, and policies and procedures for their use are in place
where the staff can read them. It is important to survey staff
periodically to help identify basic supply and equipment-
related problems. Checklists for making observations of
these structural aspects are ideal for this purpose. Appendix
5-1 includes examples of tools that can help your organiza-
tion assess any structural barriers to hand hygiene
performance.
Patient or Family Satisfaction with Staff
Performance
Surveying patients and family members can help health care
workers determine whether patient perceptions match their
own view of their hand hygiene performance.
8
There are a number of ways to survey patients and fam-
ilies. One way is to incorporate questions about health care
workers’ hand hygiene performance into your organization’s
patient satisfaction survey. However, surveying patients and
families presents challenges, including variation in patients’
and family members’ language and literacy skills, impaired
cognitive ability of respondents that may go unrealized,
impaired vision, varying obstructions in patients’ line of
vision, and differences in levels of knowledge about what
constitutes good hand hygiene practice.
Four hospitals that submitted material for the
Consensus Measurement in Hand Hygiene project
addressed patient satisfaction with their health care workers’
hand hygiene performance in their hospital satisfaction
questionnaire and are described in Text Box 5-1.
Staff Satisfaction with Products
Health care workers who believe their organization’s soap
and/or alcohol rub are irritating, drying, or smell bad are
less likely to use them. Therefore, surveying staff satisfaction
with products can help you understand reasons for poor
hand hygiene. Organizations such as the World Health
Organization have developed product satisfaction surveys.
(See Appendix 5-1 for more information on these surveys.)
Assessment of Skin Condition
Frequent hand hygiene during patient care can result in skin
irritation, so selection of acceptable and effective hand
hygiene products is important in promoting hand hygiene
adherence.
8,20
Self-assessment surveys on staff hand skin
condition can be useful in gauging the impact of hand
hygiene products on dermal tolerance. Appendix 5-1 con-
tains examples of self-assessment survey related to skin
condition.
66
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
KEY POINTS, CHAPTER 5
• Surveys are useful for measuring components
such as perceptions, attitudes, and
satisfaction.
• Strengths and limitations of surveys vary
based on the purpose and type of survey
administered.
• Some surveys, such as those listed in
Appendix 5-1, are designed to measure
multiple components. You may not need to
use a separate survey for each component you
want to measure.
• Before implementing a survey, determine
whether its reliability and validity have been
established.
• Tailor the survey you use and the way you
will administer it to the population you want
to survey and what you need to know.
• The accuracy of the results of a survey is
highly dependent on the reliability and
validity of the tool and the quality of the
implementation process.
REFERENCES
1. McColl E., et al.: Design and use of questionnaires: a review of
best practice applicable to surveys of health service staff and
patients: executive summary. Health Technol Assess 5(31):1–256,
2001.
2. Fern E.: Advanced Focus Group Research. Thousand Oaks, CA:
Sage, 2001.
67
Conducting Surveys
Text Box 5-1.
Examples of Patient Satisfaction Surveys
Eastern Maine Medical Center in Bangor, Maine, has used
student volunteers during the summer months to help obtain
patient feedback on hand hygiene using a short questionnaire.
The questions the students asked include the following:
• Has anybody talked to you about hand hygiene? (yes or
no)
• Do you know where the alcohol hand gel is? (yes or no)
• Are you seeing the staff clean their hands with soap and
water or gel before caring for you? (yes, no, or sometimes)
• Do you feel comfortable asking your health care providers
if they have washed their hands? (yes or no)
• Would you like your own alcohol hand gel? (yes or no).
(Patients who answer “yes” are given a small bottle of
alcohol-based hand rub.)
Brookhaven Memorial Hospital Medical Center in Patchogue,
New York, has added a general question on its patient
satisfaction survey that asks patients to rank their level of
satisfaction, using a five-point Likert scale, with “the adequacy
of precautions taken to protect your safety (washing hands,
wearing gloves, etc).” In the last two quarters of 2007, the
organization saw a statistically significant increase in the
positive rating of this survey item.
Greenville Hospital System in Greenville, South Carolina, uses
a patient satisfaction survey for patients seen in their
emergency department and outpatient surgery area. The survey
asks patients to rank their level of satisfaction (using a five-
point Likert scale) on “the extent to which staff cleansed their
hands with either hand gel or soap and water before providing
care.”
Spartanburg Regional Healthcare System in Spartanburg,
South Carolina, uses its patient satisfaction survey to ask “Did
your health care worker perform hand hygiene before contact
with you?” Spartanburg, which has been asking this question
on its survey for over three years, initially found that the
feedback from the patients via the survey was different (worse)
than their observational data on staff hand hygiene adherence
suggested. Spartanburg suspected that patients might not
always see staff performing hand hygiene, so it began teaching
staff to tell patients why and what they were doing when
washing or using the alcohol-based hand rub. The hospital has
since had positive patient feedback results on this question, in
the 80% to 90% range.
3. Dillman D.A., et al.: Understanding differences in people’s
answers to telephone and mail surveys. New Directions for Program
Evaluation 70:45–61, 1996.
4. Burroughs T.E., et al.: Patient satisfaction measurement strategies:
A comparison of phone and mail methods. Joint Commission
Journal on Quality Improvement 27:349–361, Jul. 2001.
5. Kellerman S.E., Herold J.: Physician response to surveys: a review
of the literature. Am J Prev Med 20:61–67, Jan. 2001.
6. Rodriguez H.P., et al.: Evaluating patients’ experiences with
individual physicians: a randomized trial of mail, internet, and
interactive voice response telephone administration of surveys.
Med Care 44:167–174, Feb. 2006.
7. McKinley T., et al.: Focus group data as a tool in assessing
effectiveness of a hand hygiene campaign. Am J Infect Control
33:368–373, 2005.
8. World Health Organization (WHO): WHO Guidelines on Hand
Hygiene in Health Care (Advanced Draft): Global Patient Safety
Challenge 2005–2006: Clean Care Is Safer Care. Geneva,
Switzerland: WHO, 2006.
9. Haas J.P., Larson E.L.: Measurement of compliance with hand
hygiene. J Hosp Infect 66:6–14, May 2007.
10. Edgman-Levitan S.: Measuring and improving patient experiences
of care. In Ransom S.B., Maulik J., Nash D. (eds.): The Healthcare
Quality Book: Vision, Strategy, and Tools. Chicago: Health
Administration Press, 2004, pp. 183-212.
11. Krueger R., Casey M.: Focus Groups: A Practical Guide for Applied
Research. Thousand Oaks, CA: Sage, 2000.
12. Institute for Healthcare Improvement (IHI): How-to Guide:
Improving Hand Hygiene. Cambridge, MA: IHI, Apr. 3, 2006.
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Tools/
HowtoGuideImprovingHandHygiene.htm (accessed Dec. 6,
2008).
13. Whitby M., McLaws M.-L., Ross M.W.: Why healthcare workers
don’t wash their hands: A behavioral explanation. Infect Control
Hosp Epidemiol 27:484–492, May 2006.
14. Pittet D., et al.: Hand hygiene among physicians: Performance,
beliefs, and perceptions. Ann Intern Med 141:1–8, Jul. 6, 2004.
15. Sax H., et al.: Determinants of good adherence to hand hygiene
among healthcare workers who have extensive exposure to hand
hygiene campaigns. Infect Control Hosp Epidemiol 28:1267–1274,
Nov. 2007.
16. Larson E.L., Aiello A.E., Cimiotti J.P.: Assessing nurses’ hand
hygiene practices by direct observation or self-report. J Nurs Meas
12(1):77–85, 2004.
17. Moret L., Tequi B., Lombrail P.: Should self-assessment methods
be used to measure compliance with handwashing
recommendations? A study carried out in a French university
hospital. Am J Infect Control 32(7):384–390, 2004.
18. Tibbals J.: Teaching hospital medical staff to handwash. Med J
Aust 164:395–398, 1996.
19. O’Boyle C.A., Henly S.J., Larson E.: Understanding adherence to
hand hygiene recommendations: The theory of planned behavior.
Am J Infect Control 29(6):352–360, 2001.
20. Larson E., et al.: Skin reactions related to hand hygiene and
selection of hand hygiene products. Am J Infect Control
34:627–635, 2006.
68
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Conducting Surveys
Appendix 5-1.
Examples of Hand Hygiene Surveys and Checklists
Developer/Source Survey/Checklist Title Components
S
t
a
f
f

K
n
o
w
l
e
d
g
e
/
C
o
m
p
e
t
e
n
c
y
A
t
t
i
t
u
d
e
s

a
n
d

B
e
l
i
e
f
s

A
b
o
u
t
H
a
n
d

H
y
g
i
e
n
e
S
e
l
f
-
R
e
p
o
r
t

o
f

H
a
n
d

H
y
g
i
e
n
e
B
e
h
a
v
i
o
r
S
t
r
u
c
t
u
r
a
l

F
a
c
t
o
r
s

(
e
.
g
.
,

p
r
o
d
u
c
t
a
v
a
i
l
a
b
i
l
i
t
y
,

e
q
u
i
p
m
e
n
t

f
u
n
c
t
i
o
n
-
a
l
i
t
y
,

w
r
i
t
t
e
n

p
o
l
i
c
i
e
s

i
n

p
l
a
c
e
)
P
a
t
i
e
n
t
/
F
a
m
i
l
y

S
a
t
i
s
f
a
c
t
i
o
n
w
i
t
h

S
t
a
f
f

P
e
r
f
o
r
m
a
n
c
e
S
t
a
f
f

S
a
t
i
s
f
a
c
t
i
o
n

w
i
t
h

P
r
o
d
u
c
t
s
o
r

P
r
o
d
u
c
t

A
v
a
i
l
a
b
i
l
i
t
y
A
s
s
e
s
s
m
e
n
t

o
f

S
k
i
n

C
o
n
d
i
t
i
o
n
E. Larson: A tool to assess barriers to adherence to hand
hygiene guidelines. Available in: Am J Infect Control
32:48–51, 2004.
E. Larson, et al.: Skin reactions related to hand hygiene
and selection of hand hygiene products. Available in: Am J
Infect Control 34:627–635, 2006. Address correspondence
to Didier Pittet, M.D., MS, Director, Infection Control
Program, University of Geneva Hospitals, 24 Rue Micheli-
du-Crest, 1211 Geneva, Switzerland;
[email protected].
E. Larson: Tools developed for research project.
Final Report of the New South Wales Hand Hygiene Campaign
Address correspondence to Clinical Excellence
Commission, GPO Box 1614, Sydney NSW 2001,
Australia; (612) 9382-7600;
http://www.cec.health.nsw.gov.au/moreinfo/cleanhands_
report.html; [email protected].
Infection Control Nurses Association (ICNA), United
Kingdom. In Audit Tools for Monitoring Infection
Control Guidelines within Acute Settings, 2004. Available
at http://www.ips.uk.net/icna/Admin/uploads/audit_tools
_acute.pdf. Address correspondence to [email protected].
Attitudes Regarding Practice
Guidelines
Hand Skin Self-assessment Tool
Hand Hygiene Guideline
Implementation Survey: Part I,
Interview with Director of
Infection Control
Hand Hygiene Guideline
Implementation Survey: Part II,
Clinical Rounds and Observation
“Clean Hands Save Lives”
Campaign Post Campaign Staff
Survey (Appendix 15))
Clean Hands Save Lives Campaign
Patient/Visitor Survey (Appendix
16)
Clean Hands Save Lives Campaign
Hand Hygiene Questionnaire
(Appendix 18)
Infection Control Audit Tools,
Hand Hygiene (Acute Setting),
(includes observation of
competency)
X
X
X X
X
X X
X
X
X X
69
70
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 5-1. (continued)
Developer/Source Survey/Checklist Title Components
S
t
a
f
f

K
n
o
w
l
e
d
g
e
/
C
o
m
p
e
t
e
n
c
y
A
t
t
i
t
u
d
e
s

a
n
d

B
e
l
i
e
f
s

A
b
o
u
t
H
a
n
d

H
y
g
i
e
n
e
S
e
l
f
-
R
e
p
o
r
t

o
f

H
a
n
d

H
y
g
i
e
n
e
B
e
h
a
v
i
o
r
S
t
r
u
c
t
u
r
a
l

F
a
c
t
o
r
s

(
e
.
g
.
,

p
r
o
d
u
c
t
a
v
a
i
l
a
b
i
l
i
t
y
,

e
q
u
i
p
m
e
n
t

f
u
n
c
t
i
o
n
-
a
l
i
t
y
,

w
r
i
t
t
e
n

p
o
l
i
c
i
e
s

i
n

p
l
a
c
e
)
P
a
t
i
e
n
t
/
F
a
m
i
l
y

S
a
t
i
s
f
a
c
t
i
o
n
w
i
t
h

S
t
a
f
f

P
e
r
f
o
r
m
a
n
c
e
S
t
a
f
f

S
a
t
i
s
f
a
c
t
i
o
n

w
i
t
h

P
r
o
d
u
c
t
s
o
r

P
r
o
d
u
c
t

A
v
a
i
l
a
b
i
l
i
t
y
A
s
s
e
s
s
m
e
n
t

o
f

S
k
i
n

C
o
n
d
i
t
i
o
n
Infection Control Nurses Association (ICNA), United
Kingdom. In Audit Tools for Monitoring Infection
Control Guidelines within the Community Setting, 2005.
Available at http://www.ips.uk.net/icna/Admin/uploads/
AuditTools2005.pdf. Address correspondence to
[email protected].
Institute for Healthcare Improvement. In How-to Guide:
Improving Hand Hygiene, A Guide for Improving
Practices Among Health Care Workers. Cambridge, MA:
Institute for Healthcare Improvement, 2006. Available at
http://www.ihi.org.
Michigan Health and Hospital Association, MHA
Keystone Center for Patient Safety & Quality, HAI
Collaborative. Available at
http://www.mhakeystonecenter.org.
Ministry of Health and Long Term Care, Ontario,
Canada. In Detailed Third Party Evaluation Report.
Available at http://www.justcleanyourhands.ca/program_
overview.php (tools 1–3),
http://www.justcleanyourhands.ca/environmental_changes.
php (tools 4–5), and
http://www.justcleanyourhands.ca/observation_tool.php
(tools 6–12). All tools are available and can be downloaded
free from the website. For more information, contact
Ministry of Health and Long-Term Care, Suite 810 1075
Bay Street, Toronto ON M5S 2B1 Canada,
416-326-6362.
Infection Control Audit Tools,
Hand Hygiene (Community
Setting)
Appendix 1. Hand Hygiene
Knowledge Assessment
Questionnaire,
Appendix 2. Checklist for the
Availability of Alcohol-based
Hand Rub and Clean Gloves
Health Care Worker Perceptions &
Beliefs Regarding Hand Hygiene
Hand Hygiene Policy/Procedure
Checklist
Hand Hygiene Structural
Assessment
(1) Appendix G: Healthcare
Worker Questionnaire (used in
the 10 Ontario pilot sites)
(2) Appendix H: Healthcare
Worker Focus Group Guide (used
in the 10 Ontario pilot sites
(3) Appendix I: Patient Discharge
Questionnaire (used in the 10
Ontario pilot sites)
(4) Assessment Tool for Health
Care Provider Hands
X
X
X
X X X
X
X
X X
X X
X
X
71
Conducting Surveys
Appendix 5-1. (continued)
Developer/Source Survey/Checklist Title Components
S
t
a
f
f

K
n
o
w
l
e
d
g
e
/
C
o
m
p
e
t
e
n
c
y
A
t
t
i
t
u
d
e
s

a
n
d

B
e
l
i
e
f
s

A
b
o
u
t
H
a
n
d

H
y
g
i
e
n
e
S
e
l
f
-
R
e
p
o
r
t

o
f

H
a
n
d

H
y
g
i
e
n
e
B
e
h
a
v
i
o
r
S
t
r
u
c
t
u
r
a
l

F
a
c
t
o
r
s

(
e
.
g
.
,

p
r
o
d
u
c
t
a
v
a
i
l
a
b
i
l
i
t
y
,

e
q
u
i
p
m
e
n
t

f
u
n
c
t
i
o
n
-
a
l
i
t
y
,

w
r
i
t
t
e
n

p
o
l
i
c
i
e
s

i
n

p
l
a
c
e
)
P
a
t
i
e
n
t
/
F
a
m
i
l
y

S
a
t
i
s
f
a
c
t
i
o
n
w
i
t
h

S
t
a
f
f

P
e
r
f
o
r
m
a
n
c
e
S
t
a
f
f

S
a
t
i
s
f
a
c
t
i
o
n

w
i
t
h

P
r
o
d
u
c
t
s
o
r

P
r
o
d
u
c
t

A
v
a
i
l
a
b
i
l
i
t
y
A
s
s
e
s
s
m
e
n
t

o
f

S
k
i
n

C
o
n
d
i
t
i
o
n
Ministry of Health and Long Term Care, Ontario,
Canada, http://justcleanyourhands.ca/implementation_
strategy_6.php.
U.S. Department of Veterans Affairs. Available at
http://www.va.gov/ncps/SafetyTopics/HandHygiene/
HHQuestionnaire.doc.
World Health Organization, World Alliance for Patient
Safety, Geneva Switzerland. From Manual for Observers,
WHO Multimodal Hand Hygiene Improvement Strategy,
2006.
(5) Placement Tool for Hand
Hygiene Products
(6) Baseline Hand Hygiene
Perception Survey (staff )
(7) Follow-up Hand Hygiene
Perception Survey (staff )
(8) Hand Hygiene Perception
Survey (senior and middle
management)
(9) Hand Hygiene Knowledge
Test (staff )
(10) Baseline Hand Hygiene Unit
Structures Survey (managers)
(11) Follow-up Hand Hygiene
Structures Survey (managers)
(12) Facility-level Situation
Assessment
On-the-spot form for immediate
confidential feedback
Hand Hygiene Questionnaire
Developed for VA-3M Six Sigma
Project (2006).
Evaluation of Tolerability and
Acceptability of Alcohol-based
Handrub Use—Method 1
X
X
X
X
X
X
X
X X
X
X X X X X
X X X X
72
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 5-1. (continued)
Developer/Source Survey/Checklist Title Components
S
t
a
f
f

K
n
o
w
l
e
d
g
e
/
C
o
m
p
e
t
e
n
c
y
A
t
t
i
t
u
d
e
s

a
n
d

B
e
l
i
e
f
s

A
b
o
u
t
H
a
n
d

H
y
g
i
e
n
e
S
e
l
f
-
R
e
p
o
r
t

o
f

H
a
n
d

H
y
g
i
e
n
e
B
e
h
a
v
i
o
r
S
t
r
u
c
t
u
r
a
l

F
a
c
t
o
r
s

(
e
.
g
.
,

p
r
o
d
u
c
t
a
v
a
i
l
a
b
i
l
i
t
y
,

e
q
u
i
p
m
e
n
t

f
u
n
c
t
i
o
n
-
a
l
i
t
y
,

w
r
i
t
t
e
n

p
o
l
i
c
i
e
s

i
n

p
l
a
c
e
)
P
a
t
i
e
n
t
/
F
a
m
i
l
y

S
a
t
i
s
f
a
c
t
i
o
n
w
i
t
h

S
t
a
f
f

P
e
r
f
o
r
m
a
n
c
e
S
t
a
f
f

S
a
t
i
s
f
a
c
t
i
o
n

w
i
t
h

P
r
o
d
u
c
t
s
o
r

P
r
o
d
u
c
t

A
v
a
i
l
a
b
i
l
i
t
y
A
s
s
e
s
s
m
e
n
t

o
f

S
k
i
n

C
o
n
d
i
t
i
o
n
World Health Organization, World Alliance for Patient
Safety, Geneva Switzerland. From http://who.int/gpsc/en/.
Questionnaire on Ward Structures
for Hand Hygiene
Questionnaire on the Perception
of Hand Hygiene and Health
Care-associated Infections for
Senior Executive Managers
Hand Hygiene Knowledge Test
for Health-care Workers
Baseline Questionnaire on the
Perception of Hand Hygiene and
Health Care-associated Infections
for Health-care Workers
Follow-up Questionnaire on the
Perception of Hand Hygiene and
Health Care-associated Infections
for Health-care Workers
WHO Hand Hygiene Structure
Quality Audit Tool
X
X X
X
X X
X X
X X
includes an
inventory
It is as important to assess the thoroughness, or technique,
with which health care workers perform hand hygiene as it
is to monitor performance itself. Gould and colleagues
point out that, “Although alcohol products were specifi-
cally intended to increase the frequency of hand hygiene at
busy times, decontamination may become cursory with
increasing workload, further reducing adequate surface
contact.”
1(p. 98)
Paradoxically, they also caution that if health
care workers assume that use of alcohol-based hand rub is
consistent with best practice, “tokenistic use at busy times
may contribute to increase in cross-infection as more areas
of the hands escape contact.”
1(p. 98)
The time health care
workers take to perform hand hygiene is not necessarily an
indication of its thoroughness. In a study Taylor undertook
to evaluate the hand hygiene techniques of health care
workers, she observed that some nurses cover all areas of
their hands with alcohol-based hand rub in 20 seconds,
whereas others fail to do so in 2 minutes.
2
The CDC hand hygiene guideline makes the following
recommendations for performing hand hygiene
3
:
• When decontaminating hands with an alcohol-based
hand rub, apply product to the palm of one hand and
rub hands together, covering all surfaces of hands and
fingers, until hands are dry. Follow manufacturer’s rec-
ommendations regarding the volume of product to use.
• When washing hands with soap and water, wet hands
first with water, apply an amount of product
recommended by the manufacturer to hands, and rub
hands together vigorously for at least 15 seconds,
covering all surfaces of the hands and fingers. Rinse
hands with water and dry thoroughly with a
disposable towel. Use towel to turn off the faucet.
• The World Health Organization’s (WHO’s) Guidelines
on Hand Hygiene in Health Care states that
understanding hand hygiene practices among health
care workers is essential when planning hand hygiene
improvement interventions; while the frequency of
hand hygiene opportunities per hour of care may be
high and the adherence rate may be high as well, the
technique of hand hygiene may fail.
4
The guidelines
include the recommendation that staff receive
education on how, when, and why to perform hand
hygiene in the discussion of strategies for successful
implementation of hand hygiene in hospitals; the
guidelines also contain detailed diagrams of the proper
techniques for the use of alcohol-based hand rub, as
well as soap and water (see Figure 6-1).
OBSERVING HAND HYGIENE TECHNIQUE
Demonstrating proper hand hygiene practices to staff is one
of the four critical aspects of a multidimensional hand
hygiene program.
5
The IHI hand hygiene intervention
package recommends that staff be observed to ensure that
they use the proper volume of hand hygiene product for a
sufficient amount of time, that they avoid recontamination
of hands after hand washing by using a paper towel to turn
off the faucet, and that they remove gloves by using correct
technique so as not to contaminate hands.
Researchers have also noted variability in the amount of
hand hygiene product used per hand hygiene episode and
73
chapter 6
ASSESSING THE THOROUGHNESS OF
HAND HYGIENE AND RELATED ASPECTS
74
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Figure 6-1.
WHO Diagram of Proper Hand-Washing and Hand Rubbing Techniques
Source: World Health Organization (WHO): WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary.
Geneva, Switzerland: WHO, 2006.
the thoroughness with which it is applied to the hands.
6,7
Widmer et al. conducted a prospective study in which they
observed 180 health care workers in a university-affiliated
geriatric hospital to evaluate the impact of a training
program on proper hand hygiene technique using alcohol-
based hand rub.
8
Before training, fewer than half used the
alcohol-based hand rub correctly, failing to use the proper
volume, applying it for too short a period of time, or not
applying it to all surfaces of the hands. After training, the
health care workers significantly improved their ability to
use the alcohol-based hand rub correctly. This led the
researchers to conclude that training in technique is key to
health care workers’ proper hand hygiene performance.
Monitoring how health care workers perform hand
hygiene can be done during routine hand hygiene observa-
tion periods, or it can be part of competency assessment (see
Chapter 3). Many organizations have periodic “competency
days” or “skills days,” during which staff review proper ways
to perform various procedures that are part of routine care
and patient safety. Examples include CPR or inserting an
intravenous line. After watching a demonstration, staff
members perform a return demonstration to show their
ability to perform the procedure or technique properly.
Incorporating the performance of proper hand hygiene,
either using soap and water or alcohol-based hand rub in
addition to glove removal, fits nicely into competency day
agendas. You can observe staff to determine whether the
proper amount of product is used, whether it is used for the
necessary amount of time, and how well all surfaces of the
hands and fingers are covered with the product.
Researchers have developed detailed data collection
methodologies, audit tools, and scoring systems for assess-
ing hand hygiene technique, as described in Text Box 6-1.
Physical Measurements of Hand Hygiene
Others have developed alternative methods to assess the
thoroughness of hand hygiene performance:
• Taylor used a dye dissolved in 70% alcohol and
poured 5 mL of the solution onto the cupped hands
of a volunteer.
2
The volunteer then closed her eyes and
“washed” her hands, as she normally would do using
running water. At the completion of the timed wash,
the researcher noted on charts, showing the front and
back of a hand, the areas not covered by the dye. This
method demonstrated to staff that hand washing was
often done poorly: 89% of participants missed some
parts of the hand surface, with parts of the thumbs,
backs of the fingers, and backs of the hands most
frequently missed.
• Aspock and Koller developed a series of exercises to
teach students proper techniques that included hand
washing as well as how to put on, use, and take off
sterile gloves.
13
The exercises, which became part of
the compulsory hygiene practices for medical students
at Vienna University, are done in a stress-free
atmosphere. One supervisor guides a group of up to
10 students through the exercises. The hand washing
exercise involves washing hands using their usual
technique with a cream-based dye while the students’
eyes are closed. Students then open their eyes and can
see by the dye what parts of their hands they missed.
In 2006 the infection preventionists at Amager Hospital
in Copenhagen, Denmark, developed an audit tool to assess
hand hygiene technique that could be used in a minimum
amount of time and at minimal expense. This method
requires staff to rub their hands with a fluorescent substance
as they would normally do with alcohol-based hand rub, and
place their hands under an ultraviolet light box to identify any
areas they might have missed. Two infection preventionists
administer the test and assess each person’s performance. On
average, it takes about seven minutes per health care worker to
administer the test and to enter the data into a computer. The
following scoring system is used to record the results:
• 0 points are given if areas are missed on the palms.
• 1 point is given if the palms are correctly covered but
the health care worker misses areas at the dorsal side
of the hands.
• 2 points are given if no area is missed, including the
distal wrists.
• Staff are also checked for long sleeves, rings, bracelets,
and watches:
— 1 point is given if no long sleeves are worn. They
define long sleeves as sleeves below the elbow.
75
Assessing the Thoroughness of Hand Hygiene and Related Aspects
76
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Text Box 6-1.
Examples of Scoring Systems for Evaluating Hand Hygiene Technique
As part of a research project in the United Kingdom in1990, Dinah Gould (2004) developed a hand hygiene audit tool and
scoring system that captured data including how long hands were washed or the alcohol-based hand rub was applied and whether
all surfaces of the hands and fingers were covered. She followed an individual nurse for two hours.
9
The “Observation Audit
Tool,”
10
shown here, was completed each time a hand hygiene opportunity was observed; whether hand hygiene was indicated
was judged in context according to the activity they had just completed. The “Scoring System for Hand Hygiene Technique,”
11
also shown here, was used to measure the components of hand hygiene technique:
Observation Audit Tool
Observation Schedule—1 form to be completed for every contact with the patient/near patient environment for 2 hours
Contact no._________________ Ward/Unit_________________ Staff grade_________________
Activity (described in full, e.g. handled
bedclothes, urinary catheter):
Hands decontaminated
Product
Time (in seconds)
Surfaces decontaminated
Drying
Pedal bin
Gloves worn
Sharps
Comments
Activities classified as clean or dirty
Yes ___ No ___
Hibisol___ Hibiscrub___ Soap___ None ___
___
Dorsal ___ Palmar ___ Interdigital ___
Thorough ___ Not thorough ___ Not dried___ N/A___
Used correctly ___ Not used correctly ___ N/A ___
Yes ___ No ___
Sterile ___ Not sterile___
Recapped ___ Not recapped ___ N/A ___
— 1 point is given if no rings are worn.
— 1 point is given if no bracelets or watches are worn.
Staff are not interrupted during the test and are allowed
as much time as they need before they put their hands into
the ultraviolet light box. Individuals are given feedback on
how they performed, and group feedback is given to each
ward. Groups with lower scores are targeted for additional
education during the following weeks.
Studies are needed that examine the effectiveness of
evaluating technique through demonstrations and the
extent to which demonstrated behavior corresponds with
actual practice. Correlating these methods with microbio-
logical assessments would strengthen the evidence base for
these approaches.
Microbiological Methods for Assessing
Thoroughness
Microbiological methods have been suggested for assessing
hand hygiene thoroughness or effectiveness. Paulson et al.
described three commonly used hand sampling methods to
evaluate hand hygiene effectiveness, which are described
briefly in Table 6-2.
14
The WHO guidelines include a detailed discussion of
the various methods used in Europe and the United States
to test the activity of hand hygiene agents.
4
These
approaches may be useful in clinical trials, but they can be
expensive and cumbersome to execute.
4
Some of the
simpler, less involved methods, such as the swab method or
finger press method, may have an application as visual tools
showing hand contamination for staff education purposes.
77
Assessing the Thoroughness of Hand Hygiene and Related Aspects
Text Box 6-1. (continued)
Examples of Scoring Systems for Evaluating Hand Hygiene Technique
Taylor also developed evaluation criteria for hand washing; the criteria were scored from zero to two, depending on whether the
technique was neglected, partially performed, or performed.
12
The 10 criteria included aspects such as the following:
• Use of soap (visible lather = 2; no contact with soap = 0)
• Rubbed hands together vigorously (vigorous rubbing = 2; minimal rubbing = 1; no rubbing = 0)
• Drying hands thoroughly (dried all surfaces = 2; dried one or two surfaces = 1; did not dry = 0)
* Chlorhexidine/hand rub on general wards other than during aseptic procedures.
** Chlorhexidine/hand rub on intensive care units.
Choice of agent:
Duration:
Number of hand surfaces
decontaminated (dorsum,
palm and interdigital
spaces):
Drying (hand washing
only)
Disposal
No agent = 0
Inappropriate agent* = 6
Appropriate agent
†
= 12
Hand washing—taken in seconds from the time the agent touched hands until hands rinsed
Hand rub—taken in seconds from the time the agent touched hands until rubbing ceased
One hand surface decontaminated = 4
Two hand surfaces decontaminated = 8
Three hand surfaces decontaminated = 12
Drying not attempted = 4
Not thorough = 6
Thorough (no residual moisture) = 12
Hands not recontaminated = 12
Hands recontaminated by touching bin lid = 0
While an extensive review of in vivo methodologies is
beyond the scope of this monograph, you can find informa-
tion about how some researchers have used these
methodologies in Appendix 6-1. If microbiologic methods
are used, consider what actions will be taken when prob-
lematic organisms are found.
OTHER ASPECTS OF HAND HYGIENE: NAIL
LENGTH, ARTIFICIAL NAILS, WEARING OF
RINGS, AND GLOVE USE
Nail Length and Artificial Nails
McGinley et al. found that the subungual areas of fingers
have high concentrations of bacteria—especially Gram-neg-
ative rods and coagulase-negative staphylococci, yeast, and
Corynebacterium—even after thorough hand washing or
surgical scrubs.
15
Moolenaar et al. studied a prolonged out-
break of Pseudomonas aeruginosa in a neonatal intensive care
unit and found an association between long natural nails
and colonization with the same organism in one nurse.
16
Both the CDC and the WHO recommend keeping natural
nails short (less than 1/4 inch long [CDC], less than 0.5 cm
[WHO]; both are listed as a “suggested recommendations,”
or Category II, in their ranking of recommendations).
3,4
Artificial nails have been studied by several researchers,
and there is growing evidence that wearing artificial nails
results in higher carriage of Gram-negative organisms and
yeast.
17,18
Several outbreaks have been described in the liter-
ature.
16,19–22
The CDC and WHO guidelines recommend
that staff having direct contact with high-risk patients not
wear artificial nails or nail extenders.
3,4
(Both the CDC and
the WHO rank the recommendation as 1A, the strongest
evidence-based recommendation in their ranking system.)
Several of those who answered the Consensus
Measurement in Hand Hygiene project survey said that
they monitor aspects of nails as part of their organization’s
overall hand hygiene program. This aspect of their hand
hygiene programs is summarized In Text Box 6-2.
78
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Table 6-1.
Commonly Used Hand Sampling Methods to Evaluate Hand Hygiene
Method
Swab method
Palm and/or finger
press method
Glove juice method
Advantage
Relatively simple and
inexpensive
Relatively simple and
inexpensive
Can reliably measure
quantities of marker
organisms
Description
The test subject’s palm and areas
between the fingers or fingertips are
swabbed with a pre-moistened cotton
swab, which is streaked across an agar
plate, for culture.
The test subjects press their palm or
fingertips directly onto an agar plate for
culture.
The test subject puts on surgical gloves,
and a microbial stripping solution is
instilled into the glove; the hands and
fingers are massaged through the glove
for one minute.
Disadvantage
Lack of reliability; cannot precisely
measure quantities of marker organ-
isms in order to estimate the true
microbial population.
Lack of reliability; cannot precisely
measure quantities of marker organ-
isms in order to estimate the true
microbial population.
More involved procedure than the pre-
vious two methods. The only method
specified by U.S. regulatory agencies
for evaluating the effectiveness of hand
hygiene products (21 CFR Section
333.470, 1994). Includes germs on
back of hand, which are less related to
transmission risk.
Source: Adapted from Paulson D.S., et al.: A close look at alcohol gel as an antimicrobial sanitizing agent. Am J Infect Control
27:332–337, 1999.
79
Assessing the Thoroughness of Hand Hygiene and Related Aspects
Text Box 6-2.
Hospitals Monitoring Health Care Workers’ Nails
Spartanburg Regional Healthcare System in Spartanburg,
South Carolina, monitors health care workers’ nails as part of
their hand hygiene program:
• Nurse volunteers directly observe staff hand hygiene
practices, including monitoring for the presence of artificial
nails. The hospital’s policy does not allow wearing of
artificial nails.
• Hospital policy does not permit long natural nails, so
managers and infection preventionists watch for this. Staff
are instructed to hold their palm in front of their nose: If
they can see their nails over the fingertips, they need to
trim the nails (see picture below).
St. Clare’s Hospital in Weston, Wisconsin, has a policy against
staff wearing long nails or artificial nails or nail extenders. The
policy went into effect at the same time the hospital opened a
new facility in 2005, with all hired staff aware that the policy
applied to all direct caregivers and those who supervise
caregivers. The infection preventionist informally monitors the
policy during routine rounds and counsels staff with artificial
nails or nails that are too long. In the three years since the
hospital opened, only a few employees have had to be
approached about artificial or long nails, and most of the time,
employees have voluntarily complied and either cut their nails
or removed artificial ones. The human resource department’s
corrective action policy covers this aspect of hand hygiene
adherence with a tiered enforcement protocol: Initially a verbal
warning is given, then a written warning, followed by one to
five days off without pay and potential termination if the
employee does not correct the infraction.
23
University Community Hospital in Tampa, Florida, monitors
staff for nail length and artificial nails or extenders. In order to
ensure a consistent approach throughout the 30 hospitals in
the Tampa Bay area, the infection preventionists in all the
hospitals developed and implemented policies at about the
same time in 2000. The infection preventionists at University
Community Hospital began by educating staff about the
reasons for the nail policy, emphasizing how important it is for
patient safety. While the infection preventionists and nurse
leaders watch for any deviations from the policy, staff
adherence has been very good, and infractions seldom occur. If
a health care worker is suspected of wearing artificial nails, he
or she is counseled by either infection preventionists or the
nurse leader.
Brookhaven Memorial Hospital Medical Center in Patchogue,
New York, has had a formal policy regarding nails since 2004.
The policy states that the wearing of artificial nails or nail
jewelry is not permitted for staff who provide patient care or
handle patient care products or food. The policy also requires
that nails be kept short enough to prevent puncturing of gloves
or harm to patients. Recognizing the impact of the “show me”
approach to education, before implementing the new policy,
staff cultured health care workers’ nails (both natural and
artificial) after they washed their hands. They were able to
show staff that there was a significantly larger bacteria count
on the nails of those who wore artificial nails than on natural
nails. Adherence to the nail policy has been consistently high;
occasionally employees are identified wearing artificial nails,
but when counseled, they have removed them. Observing for
long or artificial nails is now part of the hospital’s routine hand
hygiene observation periods.
Wearing of Rings
Observation is often used to assess the wearing of rings and
other jewelry. The relationship between wearing rings and
the transmission of microorganisms is still unclear. The
CDC guideline has categorized this as an “unresolved issue”
in need of additional research
3
; the draft WHO guidelines
also do not have a stated recommendation against the
wearing of rings but note that “the consensus recommenda-
tion is to discourage the wearing of rings or other jewelry
during health care.”
4
A number of studies, however, have
demonstrated that the skin under rings can be more heavily
colonized than areas of the skin without rings and can be a
major contributor to hand contamination.
• Trick et al. (2003) studied 66 surgical intensive care
unit nurses, culturing each staff nurse’s hands before
and after he or she performed hand hygiene; they
found that wearing rings was associated with a 10-fold
higher median count of skin microorganisms,
especially with yeast species or Gram-negative bacilli.
24
They also found a dose–response effect between ring
wearing and contamination; the concentration of
microorganisms increased as the number of rings worn
increased.
• Hoffman and Cooke surveyed 50 nurses working on
medical and surgical wards who permanently wore
rings and studied the microorganisms isolated from
skin under the rings.
25
Forty percent of these nurses
(20 nurses) had Gram-negative bacilli on the skin
under their rings, and 16 of these 20 nurses still had
most strains each time the nurses were sampled during
the five-month study.
• Salisbury et al. studied 100 hospital health care
workers who worked on general medical and surgical
units, excluding those who had used antimicrobial
soap in the previous two weeks, had artificial nails, or
were receiving antibiotics.
26
Each health care worker
who wore rings was paired with a worker from the
same unit who did not wear rings. Cultures were
taken from the solution poured over each health care
worker’s hands as they performed a 60-second friction
rinse, done both before and after a routine hand wash.
Mean total colony counts for those who wore rings
were higher before and after hand washing.
Other researchers have not found an association between
wearing rings and increased colonization with bacteria:
• Waterman et al. studied health care workers in
perioperative settings who wore rings and performed
surgical scrubs to those who did not were rings.
27
They
found no differences in the bacterial counts before or
after surgery between the ring-wearing and non-ring-
wearing study participants, and they concluded that
there was no compelling evidence that wearing rings
resulted in higher bacterial counts under gloves during
surgery.
• Fagernes et al. studied health care workers involved in
patient care who had not used antiseptic soap within
24 hours of their hand culture.
28
They found that
wearing a single plain ring did not increase the total
bacterial count on the hands.
MONITORING THE USE OF GLOVES
Both the CDC and the WHO guidelines recommend that
health care workers wear gloves to protect themselves from
acquiring infections from patients as well as to protect
patients from acquiring microorganisms that may be on the
hands of health care workers; specifically, the guidelines rec-
ommend that health care workers do the following
3,4
:
• Wear gloves when in contact with blood or other
potentially infectious body fluids, excretions,
secretions (except sweat), mucous membranes, and
non-intact skin.
• Remove gloves after caring for a patient; health care
workers should not wear the same pair of gloves when
caring for more than one patient.
• Change gloves during patient care when moving from
a contaminated body site to a clean body site.
Wearing gloves does not provide complete protection,
however, as hands can become contaminated via small
defects in the gloves or during removal of gloves. Thompson
80
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
et al. studied glove use and hand hygiene practices in an
observational study of health care workers in a long term
care facility and noted that, while gloves were used in more
than 80% of the interactions with patients when indicated,
they were changed appropriately less than 20% of the
time.
29
The CDC and WHO guidelines also emphasize that
wearing gloves does not take the place of hand hygiene.
3,4
The evidence, considerations, recommendations, and key
messages for glove use are specifically described in the
WHO’s Information Sheet 6 on Glove Use,
30
as part of the
“Clean Care Is Safer Care” suite of tools. This information
sheet clearly summarizes the WHO guidance on glove use
for health care workers and presents a useful pyramid
diagram that explains when gloves are indicated and what
type of gloves are indicated. This information can be useful
when considering the monitoring of glove use. The IHI rec-
ommends that staff competency be assessed regarding the
use of alcohol-based hand rub and proper removal of gloves
(so as not to contaminate hands with the contaminated
glove surface).
5
Monitoring of glove use by health care workers can be
incorporated into routine hand hygiene observation
periods. Glove use can also be incorporated into “skills
days” or “competency days,” as described earlier in this
chapter, during which staff could describe the indications
for wearing gloves or demonstrate proper removal of con-
taminated gloves.
KEY POINTS, CHAPTER 6
• Assessing the thoroughness (technique) of
hand hygiene by health care workers is as
important as monitoring the action (done or
not done) of hand hygiene.
• “Skills days” or “competency days” provide
regular opportunities to demonstrate and
practice proper hand hygiene technique.
• Other aspects of hand hygiene that can be
monitored include nail length, artificial nails,
wearing of rings, and proper use of gloves.
REFERENCES
1. Gould D.J., et al.: The Clean Your Hands Campaign: Critiquing
policy and evidence base. J Hosp Infect 65:95–101, 2007.
2. Taylor L.J.: An evaluation of handwashing techniques—1. Nurs
Times 19:54–55, Jan. 1978.
3. Boyce J.M., Pittet D.: Guideline for Hand Hygiene In Health-
Care Settings: Recommendations of the Healthcare Infection
Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect
Control Hosp Epidemiol 23(Suppl.):S3–S40, Dec. 2002.
4. World Health Organization (WHO): WHO Guidelines on Hand
Hygiene in Health Care (Advanced Draft): A Summary. Geneva,
Switzerland: WHO, 2006.
5. Institute for Healthcare Improvement (IHI): How-to Guide:
Improving Hand Hygiene. Cambridge, MA: IHI, Apr. 3, 2006.
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Tools/
HowtoGuideImprovingHandHygiene.htm (accessed Dec. 6,
2008).
6. Larson E.L., et al.: Quantity of soap as a variable in handwashing.
Journal of Infection Control371–375, 1987.
7. Widmer A.E., Dangel M.: Alcohol-based handrub: Evaluation of
technique and microbiological efficacy with international infection
control professionals. Infect Control Hosp Epidemiol 25:207–209,
Mar. 2004.
8. Widmer A.F., et al.: Introducing alcohol-based hand rub for hand
hygiene: The critical need for training. Infect Control Hosp
Epidemiol 28:50–54, Jan. 2007.
9. Gould D.: Systematic observation of hand decontamination. Nurs
Stand 18:39–44, Aug. 4–10, 2004.
10. Gould D., personal written communication, Mar. 2007.
11. Gould D.: Nurses’ hand decontamination practice: results of a
local study. J Hosp Infect 28:15–30, Sep. 1994.
12. Taylor L.J.: An evaluation of handwashing techniques—2. Nurs
Times 19:108–110, Jan. 1978.
13. Aspock C., Koller W.: Practice forum: A simple hand hygiene
exercise. Am J Infect Control27:370–372, 1999.
14. Paulson D.S., et al. : A close look at alcohol gel as an
antimicrobial sanitizing agent. Am J Infect Control 27:332–337,
1999.
15. McGinley K.J., Larson E.L., Leyden J.J.: Composition and density
of microflora in the subungual space of the hand. J Clin Microbiol
26:950–953, 1988.
16. Moolenaar R., et al.: A prolonged outbreak of Pseudomonas
aeruginosa in a neonatal intensive care unit: Did staff fingernails
play a role in disease transmission? Infect Control Hosp Epidemiol
21:80–85, Feb. 2000.
17. Pottinger J., Burns S., Manske C.: Bacterial carriage by artificial
versus natural nails. Am J Infect Control 17:340–344, Dec. 1989.
18. Hedderwick S.A., et al.: Pathogenic organisms associated with
artificial fingernails worn by health care workers. Infect Control
Hosp Epidemiol 21:505–509, 2000.
81
Assessing the Thoroughness of Hand Hygiene and Related Aspects
19. Foca M., et al.: Endemic Pseudomonas aeruginosa infection in a
neonatal intensive care unit. N Engl J Med 343:695–700, 2000.
20. Parry M.F., et al.: Candida osteomyelitis and diskitis after spinal
surgery: An outbreak that implicates artificial nail use. Clin Infect
Dis 32:352–357, 20001.
21. Gupta A., et al.: Outbreak of extended spectrum beta-lactamase-
producing Klebsiella pneumoniae in a neonatal intensive care unit
linked to artificial nails. Infect Control Hosp Epidemiol
25:210–215, 2004.
22. Boszczowski I., et al.: Outbreak of extended spectrum beta-
lactamase-producing Klebsiella pneumoniae infection in a
neonatal intensive care unit related to onychomycosis in a health
care worker. Pediatr Infect Dis J 24:648–650, Jul. 2005.
23. Thomas, P., R.N., B.S.N., C.I.C., St. Claire’s Hospital in Weston,
WI, personal telephone communication, Jul. 1, 2008.
24. Trick W.E., et al. Impact of ring wearing on hand contamination
and comparison of hand hygiene agents in a hospital. Clin Infect
Dis 36:1383–1390, 2003.
25. Hoffman P.N., Cooke E.M.: Micro-organisms isolated from skin
under wedding rings worn by hospital staff. BMJ 290:206–207,
Jan. 19, 1985.
26. Salisbury D.M., et al.: The effect of rings on microbial load of
health care workers’ hands. Am J Infect Control 25:24–27, 1997.
27. Waterman T.R., et al.: Comparison of bacterial counts in glove
juice of surgeons wearing smooth band rings versus those without
rings. Am J Infect Control 34:421–425, 2006.
28. Fagernes M., Lingaas E., Bjark P.: Impact of a single plain finger
ring on the bacterial load on the hands of health care workers.
Infect Control Hosp Epidemiol 28:1191–1195, 2007.
29. Thompson B.L., et al.: Handwashing and glove use in a long-term
care facility. Infect Control Hosp Epidemiol 18:97–103, 1997.
30. World Health Organization (WHO) World Alliance for Patient
Safety: Information Sheet 6: The First Global Patient Safety
Challenge: Clean Care Is Safer Care. Geneva, Switzerland: WHO,
Oct. 2006. http://www.who.int/gpsc/tools/Infsheet6.pdf (accessed
Dec. 4, 2008).
82
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 6-1.
Examples of Research Articles That Describe Microbiologic Methods for Assessing
Hand Hygiene Technique
Author(s)/Article
Kampf G.: How
effective are hand
antiseptics for the
postcontamination
treatment of hands
when used as
recommended? Am
J Infect Control
36:356–360, Jun.
2008.
Kac G., et al.:
Microbiological
evaluation of two
Type of
Microbiologic
Method
Glove juice
method
Palm and finger
press method
Results
Only the hand rub
containing 85%
ethanol was as
effective as the
antiseptic hand wash
product in reducing
colony counts. The
researchers also
found that a higher
volume of hand rub
(3.6 vs. 2.4 mL) did
not necessarily result
in better coverage of
the hands, believed
to be related to the
volunteers’
insufficiently
rubbing their hands
with the product.
A total of 50
HCWs participated
in the study, with
Methodology
Hands of 16 volunteers were
contaminated with Serratia
marcescens. After a two-minute
air-dry, the glove juice sampling
procedure was done. The
volunteers then washed their
hands using a nonmedicated soap.
Hands were recontaminated with
inoculums of Serratia, and each
volunteer then applied one of four
different blinded hand rubs (each
with a different concentration of
ethanol) and rubbed his or her
hands until dry. A control
product (antiseptic hand wash)
was similarly used. Repeat glove
juice sampling was done following
each product application.
The 6-month study used a
crossover design in five wards of a
750-bed tertiary care university
Description of
Microbiologic Technique
The researchers instilled 75
mL of sterile stripping fluid
into each glove, and the
volunteer's wrist was secured.
The volunteer’s hands were
massaged through the glove
by an attendant for 60
seconds. Aliquots of 5 mL of
glove juice were removed
from each glove and diluted
in 5 mL of phosphate-
buffered saline and diluted
with product neutralizers.
Spread plates and spiral plates
were prepared from each
dilution on tryptic soy agar
and incubated at 30ºC for 48
hours, at which time colony
counts were done.
Before and after the HH
procedures, palm and
fingertips were pressed onto
83
Assessing the Thoroughness of Hand Hygiene and Related Aspects
Appendix 6-1. (continued)
hand hygiene
procedures achieved
by health care
workers during
routine patient care:
a randomized study.
J Hosp Infect
60:32–39, May
2005. Errata in J
Hosp Infect
62:129, Jan. 2006.
Pessoa-Silva C.L., et
al.: Dynamics of
bacterial hand
contamination
during routine
neonatal care.
Infect Control
Hosp Epidemiol
25:192–197, Mar.
2004.
Lucet J.C., et al.:
Hand
contamination
before and after
different hand
hygiene techniques:
a randomized
clinical trial.
J Hosp Infect
Fingertip press
Fingertip press
200 cultures done
(100 palms, 100
fingertips). Hand
rubbing yielded a
significantly greater
reduction in the
bacterial load than
hand washing.
A total of 398
samples were taken
from HCW’s
hands, with 360 of
them culture
positive.
A total of 43
volunteers
participated in the
study, with a total
of 516 cultures
obtained (258
before and 258 after
HH); 383
specimens were
hospital; 10 health care workers
(HCWs) from each ward were
randomly assigned to perform
hand hygiene (HH) with an
unmedicated soap and alcohol-
based hand rub (ABHR); the two
HH episodes were separated by
six hours. Imprints of the palm
and fingertips on the volunteer’s
dominant hand were taken at the
same time before and within one
minute following the HH
procedure.
The study took place in a 20-bed
neonatal unit in a large acute care
teaching hospital. An imprint of
the five fingertips of the dominant
hand was obtained before and
after HH, as well as at the end of
a sequence of care.
The two-month study was done
in seven wards, with five to seven
volunteers chosen from each
ward. Each volunteer performed
six HH techniques in random
order immediately following a
health care procedure:
• Hand washing with an
antiseptic soap for 10, 30, and
blood agar plates containing
residual antiseptic
neutralizers, using separate
plates for each. Plates were
incubated aerobically at
37ºC for 48 hours, with
colony counts at 24 and 48
hours. Colony counts were
done on each plate, with
the maximum count of 300
colony forming units. Plates
with higher counts were
considered confluent
growth. Bacteria were
identified using standard
techniques.
Commercial contact plates
were used for the imprint
of the five fingertips of the
HCW’s dominant hand.
Fingertips were pressed for
3 seconds onto a plate.
Plates were incubated in
the laboratory at 35ºC
under aerobic conditions,
and colony counts were
read at 24 and 48 hours. A
maximum colony count
was fixed at 300 colony-
forming units; anything
beyond this was confluent
growth and was not
counted. Bacteria were
identified using standard
techniques.
Trypticase-soy agar plates
were used for the cultures,
and fingertips were pressed
onto the plates for 15
seconds each. Residual
antiseptic activity was not
inactivated in the culture
media. Cultures were done
both before and within 1
Type of Microbiologic Description of
Author(s)/Article Methodology Method Microbiologic Technique Results
84
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 6-1. (continued)
50:276–280, Apr.
2002.
Doebbeling B.N.,
et al.: Comparative
efficacy of
alternative hand-
washing agents in
reducing
nosocomial
infections in
intensive care units.
N Engl J Med
327:88–93, Jul. 9,
1992.
Larson E.L., et al.:
Quantity of soap as
a variable in
handwashing.
Infection Control
8:371–375, Sep.
1987.
Variation on glove
juice method
Variation on glove
juice method
culture positive.
Bacterial counts
before HH were not
significantly
different. Bacterial
counts after using
the antiseptic soap
or the ABHR were
significantly lower
than those obtained
after washing with
the unmedicated
soap.
A total of 328 hand
cultures were
obtained after hand
washing. The rate
of hand carriage was
lower for the
chlorhexidine-
washed hands than
for hands rubbed
with the ABHR.
Overall, there was a
nonsignificant trend
for fewer infections
in the group of
patients cared for by
HCWs who washed
with chlorhexidine
There were
significant
reductions in
colony forming
units between hand
washing products,
and the volume of
product used (3 mL
yielded greater
60 seconds
• Hand washing with an
unmedicated soap for 10 and
30 seconds
• Hand rubbing with ABHR
At least 6 hours separated HH
episodes if they occurred on the
same day. After each HH episode,
all five fingertips on the dominant
hand were pressed onto agar.
Prospective crossover trial over
eight months of 1,894 adult
patients in three intensive care
units (ICUs), with HCWs using
either chlorhexidine or 60%
ABHR or an optional use of a
nonmedicated soap. Health care–
associated infection rates and HH
adherence were monitored
prospectively.
One aspect of this study used 40
healthy adult volunteers, who
were randomly assigned to one of
four hand washing agents:
• Antiseptic containing
chlorhexidine
• Two ABHRs
• A liquid non-antimicrobial
soap
minute after the HH
technique. Plates were
incubated at 37ºC under
aerobic conditions; colony
counts were done at 48
hours of incubation. As in
the previous studies, colony
counts were done up to
300 colony-forming units,
after which growth was
considered confluent.
Bacteria were identified
using standard techniques.
Cultures were taken ran-
domly from HCWs’ hands
in each unit after they had
cared for a patient selected
for observation. Each hand
was placed in a separate
sterile bag with 15 mL of
tryptic soy broth supple-
mented with Tween 80,
lecithin, sodium oleate, and
sodium sulfite and agitated
for 30 seconds. From each
bag an aliquot of 0.1 mL
was pipetted onto a trypti-
case soy agar plate, and an
equal volume was pipetted
onto a MacConkey agar
plate. All plates were incu-
bated at 35ºC for 24 hours,
after which colonies were
identified using standard
microbiologic techniques.
Test subjects inserted their
dominant hand into a
sterile polyethylene bag
containing 50 mL of sterile
distilled water containing
lecithin, sodium thiosulfate,
sodium oleate, protease
peptone, tryptone, and
Tween 80. The entire hand
Type of Microbiologic Description of
Author(s)/Article Methodology Method Microbiologic Technique Results
85
Assessing the Thoroughness of Hand Hygiene and Related Aspects
Appendix 6-1. (continued)
Hoffman P.N., et
al.: Micro-
organisms isolated
from skin under
wedding rings worn
by hospital staff.
BMJ
290(6463):206–20
7. Jan. 1985.
Swab method
reduction than 1
mL).
Gram-positive
organisms were
significantly
increased at ring
sites (mean of
1,600/swab from
skin under rings
versus 180/swab
from control sites, p
< 0.001). Twenty of
the 50 nurses also
had Gram-negative
organisms on the
skin under their
rings, with a mean
of 730/swab; 16 of
the original 20
nurses also had
Gram-negative
bacilli on at least
one occasion over
the 5-month study.
Bacteriophage and
serological typing of
the organisms
showed the same
strain to be
persistently isolated
from most test
subjects.
Within each group, subjects were
assigned to use either 1 mL or 3
mL of soap or rub per hand wash.
Each subject washed his or her
hands 15 times per day for 5 days.
Fifty nurses who worked on
medical and surgical wards who
permanently wore rings
participated in the research study.
Rings were removed, and the
investigators swabbed the skin
underneath with a swab that
neutralized any residual
antiseptics. A similar area on a
non-adjacent finger on the same
hand was similarly swabbed as a
control site. Nurses whose ring
sites grew Gram-negative bacteria
had additional samples taken
from the same sites over a five-
month period of time. At the end
of the study, samples were taken
from all nurses still working at the
hospital.
surface was rubbed
vigorously through the wall
of the bag for 3 minutes. A
0.1 mL volume of each of
serial dilutions was placed
on trypticase soy agar
containing yeast extract,
Tween 80, and 5% sheep
blood. Plates were
incubated at 37ºC for 48
hours, and colonies were
counted.
Swabs were streaked onto
plates containing casein,
yeast extract, lactose and
glucose agar, and
MacConkey agar; Gram-
negative bacilli were
identified using standard
techniques. The lower limit
for detection was 10
colony-forming units.
Type of Microbiologic Description of
Author(s)/Article Methodology Method Microbiologic Technique Results
“Hand hygiene is the entrance door to better infection control
and safer patient care.”
1
There is great global interest in improving hand hygiene
adherence. This chapter describes only a few of the many ini-
tiatives that are under way, with an emphasis on the
measurement tools and approaches used by the World Health
Organization (WHO) and those used in Australia, Canada,
England, and Scotland. Most of the tools are publicly available
and are well worth considering for use in your organization.
Most tools have been widely field tested, and reliability and
validity have been established for many of them when used in
conjunction with the available training programs. Excerpts
from several of these tools are included in the Tool Appendix.
WORLDWIDE EFFORTS: THE WHO
GLOBAL PATIENT SAFETY CHALLENGE,
“CLEAN CARE IS SAFER CARE”
In 2004, The WHO World Alliance for Patient Safety
(WAPS) initiated a global response to the problem of health
care–associated infection.
2
The overall aim is to reduce
health care–associated infection by strengthening practices
in the areas of blood safety, infection safety, and clinical pro-
cedure safety, as well as water, sanitation, and waste
management safety. The leader of the Global Patient Safety
Challenge initiative is Professor Didier Pittet, M.D., M.S.
A major emphasis of the initiative is the promotion of
hand hygiene in health care. The first Global Patient Safety
Challenge, “Clean Care is Safer Care,”
3
launched in
October 2005, has expanded educational and promotional
tools developed initially for the Swiss national hand hygiene
campaign to a worldwide program. The initiative aims to do
the following:
• Increase global awareness of health care–associated
infections as a serious issue for patient and health care
worker safety.
• Stimulate countries to commit to making progress in
these areas.
• Identify and test sound recommendations and
strategies to improve infection control interventions in
health care settings worldwide.
4
As of September 2008, this challenge to curb the spread
of infection through better hand hygiene has been accepted by
governments in more than 120 countries, representing more
than 85% of the world’s population. Early results demonstrate
significant improvement in hand hygiene compliance in all
settings where the WHO Hand Hygiene Improvement
Strategy has been implemented, in particular in Australia,
Belgium, Hong Kong, Italy, Mali, and Switzerland.
As part of the “Clean Care is Safer Care” initiative, the
WHO developed guidelines for hand hygiene that include
a five-part multimodal hand hygiene improvement strategy
for organizations to implement. The improvement strategy
includes the following:
• Structural system changes, such as making alcohol-
based hand rub available at the point of care
• Training and education
• Observation of hand hygiene performance and
feedback
87
chapter 7
INTERNATIONAL HAND HYGIENE
MEASUREMENT TOOLS AND
IMPROVEMENT EFFORTS: LEADING
THE WAY TO BROADSCALE CHANGE
• Reminders in the workplace
• Creation of a safety culture
A separate document, the “Guide for Implementation”
of the five-part multimodal improvement strategy, is a step-
by-step guide to implementing change. It includes a toolkit
with detailed forms, instructions, educational posters,
measurement tools, and an observation tool. The guide and
all tools and materials are currently available in the “Pilot
Implementation Pack,” which your organization can receive
by enrolling as a test site at http://www.who.int/
gpsc/country_work/application_form/en/index.html.
Several of these tools, such as surveys, are described in pre-
vious chapters, including Chapter 5.
The WHO validated the improvement toolkit in sites
in the six WHO regions of Africa, America, Eastern
Mediterranean, Europe, Southeast Africa, and the Western
Pacific areas. The final WHO “Guide for Implementation”
and associated tools will be available to the public on the
WHO Web site during 2009.
WHO Observation Tool
The observation tool “Manual for Observers,” included in
the WHO “Guide for Implementation” toolkit,
5
was
reviewed as part of the Consensus Measurement in Hand
Hygiene project and deserves special mention:
• It is user-friendly but also quite sophisticated.
• It collects data at the level of each hand hygiene
opportunity.
• For each opportunity, you can record the hand
hygiene indication associated with the five moments,
what the action was (wash, rub, or missed), and the
professional category of the person observed.
• It has been used and validated extensively and
translated into several languages.
• It has been used as a model for instrument
development for nationwide hand hygiene promotion
campaigns in more than 25 countries, including
Australia, Canada, and the United Kingdom.
Detailed instructions for training observers are
included in the toolkit.
NATIONAL AND REGIONAL EFFORTS
National or regional officials in many countries are leading
large-scale measurement and improvement initiatives in
several countries, often in conjunction with the WHO
Global Patient Safety Challenge. A few of these initiatives
are described below.
England and Wales: “cleanyourhands” Campaign
The “cleanyourhands” campaign, launched in England and
Wales by the National Patient Safety Agency (NPSA) in
April 2005,
6
is modelled on the Geneva campaign.
7
It is a
four-year program to address the many complex reasons
behind low adherence to hand hygiene guidelines and
involves the use of alcohol-based hand rub near the patient,
posters, patient empowerment materials, and audits and
feedback every six months. Each National Health Service
(NHS) acute care trust (hospital) received a toolkit to help
deliver the campaign. More information and tools used in
the campaign are available at http://www.npsa.nhs.uk/
cleanyourhands/.
The “cleanyourhands” campaign has been highly suc-
cessful. Procurement of soap and alcohol-based hand rub
has tripled; results as of December 2007 show that each
extra 1 mL of hand rub per patient bed day was strongly
associated with a 1% reduction in rates of methicillin-resist-
ant Staphylococcus aureus (MRSA) bacteremia. Preliminary
results from the National Observational Study to Evaluate
the cleanyourhands Campaign (NOSEC) study that is
independently evaluating the campaign’s effectiveness can
be found in Stone et al.,
8
with the most recent results
available at http://www.idrn.org/nosec.php and
http://www.npsa.nhs.uk/cleanyourhands/in-hospitals/
independent-evaluation/nosec.
The Hand Hygiene Observation Tool
The NOSEC researchers are conducting a three-year cluster
randomized controlled trial of a feedback intervention to
improve compliance on 64 wards in 16 hospitals across
England. In order to standardize observation measurement
for the trial, Stone and colleagues
8
developed the Hand
Hygiene Observation Tool.
9
Standard operating procedures
in the form of a training instruction manual, which
88
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
includes a simplified tool and rules for classifying hand
hygiene behavior more completely, were also developed.
The training materials are extensive, and you should expect
to spend one to three hours training each observer on the
use of the Hand Hygiene Observation Tool. The Hand
Hygiene Observation Tool and standard operating proce-
dures are available on the NOSEC Web site,
http://www.idrn.org/nosec.php.
The Hand Hygiene Observation Tool allows you to
collect data according to the level of risk of each patient
contact (for example, before a low-risk contact, after high-
risk contact) and to record when episodes of hand hygiene
behavior were difficult to observe. Instructions include how
to avoid the issue of double counting (after one patient and
before the next) and how to conduct structural counts of
the number of soap and alcohol dispensers present.
General recommendations for data collection with the
Hand Hygiene Observation Tool include observation for
at least 20 minutes per session and the observation of at
least 15 hand hygiene episodes per session. Within the
Feedback Intervention Trial, observation occurs one hour
per month, at the same time each month, on each of the
64 wards.
The interrater reliability of the Hand Hygiene
Observation Tool was assessed based on 1389 observations.
A description of the methodology used to assess reliability is
included in Text Box 3-8 in Chapter 3, and further infor-
mation is available in McAteer et al.
9
Ontario, Canada: “Just Clean Your Hands”
Program
Ontario, Canada’s “Just Clean Your Hands” program
10
is an
evidence-based hand hygiene program that builds on the
work done by the WHO and the United Kingdom. As a
provincewide hand hygiene program, it is available to all
acute care settings in Ontario. Like the WHO campaign,
the improvement program incorporates a communications
toolkit, ways to demonstrate senior management and
administration support, and information on environmental
modifications, champions and role models, education of
health care workers, and observation and feedback. The
“Just Clean Your Hands” program, along with a current
reference list and frequently asked questions, can be down-
loaded from http://www.justcleanyourhands.ca. The
program was pilot tested in 10 Ontario hospitals from
December 2006 to August 2007. It was launched in March
2008, with regional training sessions across the province.
A comprehensive hand hygiene program, which
includes a set of data collection tools and training materials,
was developed as part of the “Just Clean Your Hands”
program, under the direction of Clare Barry and Liz
McCreight in the Ontario Ministry of Health and Long-
Term Care. The program includes an implementation
guide; train-the-trainer sessions; tools and materials such as
online training modules, a hand care program, and posters;
an audit process and observation tool; a Web site
(http://www.justcleanyourhands.ca), and support and guid-
ance from the ministry staff during and after program
implementation.
The Canadian Patient Safety Institute started the
national “STOP! Clean Your Hands,” campaign in 2007.
11
The Canadian Patient Safety Institute has adopted the
Ontario audit tool and training component as part of its
national campaign.
Ontario Observation Tool
The Ontario observation tool, which was adapted from the
WHO observation tool, clearly defines the indications to
observe; it can be used to observe single or multiple types of
indications at the same time. It allows you to calculate
adherence rates separately for each type of indication and
each health care worker category (for example, nurses per-
formed hand hygiene before patient care, 80% adherence;
physicians performed hand hygiene after patient care, 80%
adherence). The numerator (the number of times hand
hygiene was performed for a specific indication/specific
health care worker category) and denominator (the number
of observed hand hygiene indications for specific hand
hygiene indications observed) are reported separately for
each type of indication and each health care worker cate-
gory; this provides data for developing targeted and
appropriate interventions to improve adherence.
Developers of the tool recommend not reporting overall
facilitywide rates because they can be misleading and
89
International Hand Hygiene Measurement Tools and Improvement Efforts: Leading the Way to Broadscale Change
difficult to interpret, as adherence for the different indica-
tions for hand hygiene and adherence by the different types
of health care workers can vary widely across the facility and
by health care worker type.
A hallmark of this program is the importance and thor-
oughness of training materials. The training material
includes a PowerPoint presentation on hand hygiene and a
DVD with 15 simulated clinical situations for the trainee to
observe and check off hand hygiene observations. An
answer sheet allows an observer to compare his or her
answers to the correct responses. The developers estimate
that training an observer takes between three and six hours.
The interrater reliability of the Ontario tool was tested
using two pairs of trained observers and found to be 94%,
based on 56 observations over two weeks during 20-minute
observation periods. The tool developers recommend
reassessing reliability at regular intervals and whenever new
staff are collecting data.
New South Wales, Australia: “Clean Hands
Save Lives” Campaign
The 12-month “Clean Hands Save Lives” campaign was a
joint initiative of the Clinical Excellence Commission and
the New South Wales Department of Health. Changes
introduced by the campaign were designed to assist in the
implementation of existing evidence-based guidelines and
to aid health facilities in addressing identified problems
and barriers associated with current local hand hygiene
activities.
12
The “Clean Hands Save Lives” campaign, launched in
March 2006, was designed to reduce multiple-drug-resist-
ant organism (MDRO) infections through improving
hand hygiene adherence. Combining campaign method-
ologies from a variety of sources,
7,13–15
the “Clean Hands
Save Lives” campaign used a multimodal approach to
increase the use of alcohol-based hand rubs and, as a
result, reduce MDRO infections. In addition, this cam-
paign used regular feedback on hand hygiene performance
to improve hand hygiene adherence. Strategies employed
included the following:
• Project officers were appointed to each area health
service to coordinate local campaigns.
• Dissemination of campaign collateral materials was
linked to key messages of the campaign.
• The University of Geneva Hospitals “Talking Walls”
strategy was adapted for worldwide use by the WHO.
7
• Alcohol-based hand rubs were placed at the point of
patient care in each facility to help busy staff decon-
taminate their hands before and after patient contact.
• Alcohol-based hand rub usage and distribution were
measured through facilities in New South Wales.
• Adherence to hand hygiene guidelines was audited,
and staff were given feedback on their performance.
New South Wales Data Collection Tools
Standardized data collection tools were used to assist staff in
evaluating local implementation of the “Clean Hands Save
Lives” campaign and provide de-identified data for
statewide aggregation and analysis. The tools and instruc-
tions used for observation, feedback, and training are
available at http://www.cec.health.nsw.gov.au/pdf/clean-
hands/report/appendix14.pdf.
During the campaign, known independent observers
collected data in 20-minute observation periods, recogniz-
ing that the Hawthorne effect is inherent in this approach.
At the end of the 20 minutes, data collectors gave verbal
and written feedback to staff, using a structured form. Data
collection staff were advised to stress the positive findings
first; if there were negative findings, they gave examples and
suggestions for improvement, and they asked staff to
explain why they did not adhere to guidelines.
The New South Wales observation form lists specific
tasks as opportunities for transmission in low-, medium-,
and high-risk categories. For example, low risk includes
making clean beds and having contact with notes, tele-
phones, or computers; medium risk includes moving a
patient into or out of bed and donning and removing
gloves; high risk includes suctioning, phlebotomy, and
being exposed to bodily secretions. Risk categories were
based on the Fulkerson risk scale.
16
Campaign Achievements
According to the final report, the New South Wales “Clean
Hands Save Lives” resulted in the following achievements:
90
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
• There was a 15.1% improvement in hand hygiene
adherence across all professional groups in New South
Wales health facilities, with the greatest improvement
(27.1%) in low-risk hand hygiene behaviors.
• The availability of alcohol-based hand rubs in patient
care areas was improved to 70% of all available acute
beds.
• An increased number of staff reported understanding
and having knowledge of hand hygiene, which was
reflected in observed hand hygiene adherence.
• Staff confidence in using alcohol-based hand rubs
increased by 17.9% by the end of the campaign.
• The number of MDRO infections decreased. In
particular, MRSA infections in intensive care unit
patients’ sterile body sites decreased from 5.28 per
10,000 occupied bed days to 3.92 per 10,000
occupied bed days.
Interestingly, results from a statewide follow-up audit
showed that health services areas that continued to monitor
and audit hygiene in their hospitals showed additional
improvement in adherence, while areas that stopped moni-
toring hand hygiene showed a decrease to nearly
pre-campaign levels.
17
More information about campaign
achievements is available in the “Clean Hands Save Lives”
final report.
12
Health Protection Scotland: “Germs. Wash Your
Hands of Them”
Scotland’s national hand hygiene campaign, “Germs. Wash
Your Hands of Them,” was launched in January 2007 and
is being delivered by Health Protection Scotland on behalf
of the Scottish Government Health Directorate.
18
It is part
of a pledge to the WHO Global Patient Safety Challenge,
“Clean Care is Safer Care.” This campaign is the first of its
kind in the United Kingdom, and its core aim is to improve
hand hygiene and reduce avoidable illness by using a social
marketing approach. Scotland’s campaign is unique in that
it is aimed at both the general public and health care staff.
The campaign has two key elements, both of which aim to
achieve sustainable change in culture:
• A public campaign using TV and press
advertisements, including material that specifically
targets children. An initial evaluation of this campaign
found that it was successful in many areas. For more
information, visit
http://www.washyourhandsofthem.com/campaign/ca
mpaign_evaluation.html.
• A second campaign aimed at raising awareness among
NHS staff, patients, and visitors ran alongside the
public campaign. The third phase of work will
continue through March 2011. Additional
information about the health care campaign is
available at
http://www.scotland.gov.uk/Topics/Health/NHS-
Scotland/19529/2005.
Additional information and quality improvement
resources related to hand hygiene, including an interactive
coaching online quiz and sample policies, are available at
the Healthcare Associated Infection & Infection Control
Resource Centre for the hand hygiene model infection
control policy, at http://www.hps.scot.nhs.uk/haiic/
ic/handhygiene.aspx.
Data Collection Tools and Auditing Method
Following a review of available hand hygiene audit tools,
the Scotland national campaign received permission to
adapt a tool used by the Infection Control Nurses
Association. An electronic tool was developed and installed
on tablet personal computers that were provided to all local
health board coordinators for auditing. The Scottish gov-
ernment funded one local health board coordinator for each
NHS area. The government audited for adherence to the
WHO’s “Five Moments for Hand Hygiene” (shown in
Figure 1-1 in Chapter 1). The electronic tool incorporated
data quality assurance features designed to reduce the risk of
missing data or illogical entries.
The Scottish government also produced a National
Minimum Audit Dataset Protocol and Resource Pack to
complement the audit tool, which contained detailed defi-
nitions and a standardized approach to data collection.
Extensive training was provided for auditors and other asso-
ciated infection control staff, including observation of
91
International Hand Hygiene Measurement Tools and Improvement Efforts: Leading the Way to Broadscale Change
health care activities on video while the local health board
coordinators completed an audit in real time.
During data collection, the auditors were instructed to
be unobtrusive and state that they were in the area to
observe aspects of infection control practices rather than
hand hygiene specifically. An individual audit was defined
as the monitoring conducted in one physical location, such
as observations taking place on one ward. Each auditor
completed an audit of 20 opportunities within one day, and
10 audits were performed during the two-week mandatory
audit period.
Campaign Achievements
In November 2007, the Cabinet Secretary for Health and
Well-being set a target goal of at least 90% adherence by
November 2008 . Health Protection Scotland has published
the Compliance with Hand Hygiene Audit Report based on
the first four periods when local health board coordinators
undertook audits throughout their NHS boards.
18
This
report was one of the first to present hand hygiene adher-
ence at the country level.
Data released in October 2008 present national find-
ings, as well as results, stratified by local health directorate
and type of health care worker. There has been continued
improvement in adherence from each audit period to the
next, with statistically significant improvements over time
(p < .001). For example, countrywide compliance in 2007
increased from 68% to 87% and then in 2008 from 88% in
Quarter 1 to 90% in Quarter 2. Because there is local vari-
ation in adherence, activities are under way to target
initiatives based on local assessments of need. In summary,
hand hygiene compliance within NHS Scotland is improv-
ing. Continued focus will be required to support
compliance with the target of at least 90% to ensure long-
term sustainability in all NHS boards.
18
Testing of a Measurement Tool for Use in
Developing Countries
Pashman et al. sought to design and test an easy-to-use hand
hygiene surveillance instrument for hospitals in developing
countries.
19
They pilot tested the instrument for three
months in nine hospitals in China as part of the WHO ini-
tiative in Beijing. The materials included a step-by-step,
detailed instruction manual for implementing robust sur-
veillance methods. The form also included an assessment of
structural factors such as availability of soap, alcohol-based
hand rub, and towels.
Pashman et al. focused on measuring four essential
opportunities: after patient contact, before patient contact,
after contact with environmental surfaces within a patient’s
immediate area, and after removal of gloves. The form cap-
tures the type of personnel (physician, nurse, other clinical,
and other nonclinical) and thoroughness of hand hygiene
action (for example, washing > 15 seconds, washing < 15
seconds, using alcohol-based hand rub). For each observa-
tion session, the observer was instructed to obtain data on
at least 10 hand hygiene opportunities. The tool is available
in Pashman et al.
19
KEY POINTS, CHAPTER 7
• Many international hand hygiene
improvement initiatives that are under way
were stimulated by the WHO WAPS Global
Patient Safety Challenge initiative launched in
2005.
• International hand hygiene improvement
initiatives have invested considerable time and
effort in developing and testing valid and
reliable measurement tools and training
programs.
• Many toolkits are publicly available online
and should be considered for use when
searching for rigorous measurement tools and
methods.
REFERENCES
1. Pittet D., University of Geneva Hospitals, Geneva, Switzerland,
and leader, World Health Organization First Global Patient Safety
Challenge, personal communication, Jun. 11, 2007.
2. Pittet D., Donaldson L.: Clean care is safer care: A worldwide
priority. Lancet 366:1246–1247, 2006.
3. World Health Organization: Clean Care Is Safer Care.
http://www.who.int/gpsc/resources/newsalert/dec2007/en/index.ht
ml (accessed Aug. 15, 2008).
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
92
4. Allegranzi B., Pittet D.: Healthcare-associated infection in
developing countries: Simple solutions to meet complex
challenges. Infect Control Hosp Epidemiol 12:1323–1327, Dec. 28,
2007.
5. World Health Organization (WHO), World Alliance for Patient
Safety: Manual for Observers. Geneva, Switzerland: WHO, 2006.
6. National Patient Safety Agency (NPSA): cleanyourhands Campaign.
http://www.npsa.nhs.uk/cleanyourhands/ (accessed Aug. 15,
2008).
7. Pittet D., et al.: Effectiveness of a hospital-wide programme to
improve compliance with hand hygiene. Lancet 356:1307–1312,
Oct. 14, 2000. Errata in Lancet 356:2196, Dec. 23–30, 2000.
8. Stone S., et al.: Early communication: Does a national campaign
to improve hand hygiene in the NHS work? Initial English and
Welsh experience from the NOSEC study (National Observational
Study to Evaluate the cleanyourhands Campaign). J Hosp Infect
66:293–296, Jul. 2007.
9. McAteer J., et al.: Development of an observational measure of
health care worker hand-hygiene behaviour: The Hand-Hygiene
Observation Tool (HHOT). J Hosp Infect 68:222–229, Mar. 2008.
10. Ontario, Canada, Ministry of Health and Long-Term Care: Just
Clean Your Hands. http://www.justcleanyourhands.ca (accessed
Dec. 5, 2008).
11. Canadian Patient Safety Institute: STOP! Clean Your Hands.
http://www.patientsafetyinstitute.ca/uploadedFiles/News/Pilot%20
Sites%20letter%20(FINAL).pdf (accessed Dec. 5, 2008).
12. Pantle A., Fitzpatrick K.: Clean Hands Save Lives: Final Report of
the NSW Hand Hygiene Campaign. 2007. Sydney, Australia:
Clinical Excellence Commission.
www.cec.health.nsw.gov.au/pdf/cleanhands/report/final-report.pdf
(accessed Dec. 5, 2008).
13. Larson E., Killien M.: Factors influencing handwashing behavior
of patient care personnel. Am J Infect Control 10:93–99, 1982.
14. Pittet D.: Improving adherence to hand hygiene practice: A
multidisciplinary approach. Emerg Infect Dis 7:381–386,
Mar.–Apr. 2001.
15. Pittet D., et al.: Cost implications of successful hand hygiene
promotion. Infect Control Hosp Epidemiol 25:264–266, Mar. 2004.
16. Rotter M.L.: Hand washing and hand disinfection. In Mayhall
C.G. (ed.): Hospital Epidemiology and Infection Control. Baltimore:
Williams & Wilkins, 1996, pp. 1052–1068.
17. Pantle A., Director of Clinical Practice Improvement, Clinical
Excellence Commission, New South Wales, personal
communication, Nov. 4, 2008.
18. Health Protection Scotland (HPS): National Hand Hygiene NHS
Campaign: Compliance with Hand Hygiene—Audit Report.
Glasgow: HPS, Oct. 2008.
http://www.documents.hps.scot.nhs.uk/hai/infection-
control/national-hand-hygiene-campaign/audit-report-2008-10-01
.pdf (accessed Dec. 5, 2008).
19. Pashman J., et al.: Promotion of hand hygiene techniques through
use of a surveillance tool. J Hosp Infect 66:249–254, 2007.
93
International Hand Hygiene Measurement Tools and Improvement Efforts: Leading the Way to Broadscale Change
Once you have selected your measurement method(s) and
begun to collect data, the next challenge you will face is
how best to display your results. It is important to design
your data display as an effective tool that communicates
results, is easy to interpret, and easy to use. This chapter
considers some of the ways that you can approach dis-
playing data and provides some examples from health care
organizations.
CREATING A HAND HYGIENE DASHBOARD
A quality dashboard is a data visualization tool for reporting
information about related key performance indicators to
leadership and customers. A dashboard provides a quick, at-
a-glance summary of a process and/or product performance,
which is often desired by top management and boards of
directors.
1
A hand hygiene dashboard can be organized according
to the Donabedian framework of structure, process, and
outcome.
2,3
The dashboard can include structural measures
of the availability of alcohol-based hand rub or liquid soap
dispensers and gloves, together with the traditional process
measures, such as the observed percentage of hand hygiene
actions compared with hand hygiene opportunities, and
outcome measures such as patient satisfaction with hand
hygiene or infection rates. A mock hand hygiene dashboard
is provided in Figure 8-1.
REPORTING DATA BY UNIT AND TYPE OF
HEALTH CARE WORKER
One of the most dramatic lessons learned by leaders of the
multisite improvement initiative in Ontario, Canada—
“Just Clean Your Hands” program
4
—relates to how
adherence rates are reported. After pilot testing, the leaders
recognized that overall facilitywide rates were not useful for
identifying opportunities for improvement.
5
Instead, they
realized that data are most useful when stratified and
reported by subgroups, such as specific hand hygiene indi-
cation or type of health care worker. As shown by research
studies summarized in Appendixes 3-2 and 3-3 in Chapter
3, stratified rates allow you to identify problem areas and
focus training efforts.
Several examples of reporting data by unit and disci-
pline were received in response to the Consensus
Measurement in Hand Hygiene project call for measure-
ment methods, a few of which are displayed in Text Box
8-1.
STATISTICAL PROCESS CONTROL CHARTS
Statistical process control charts are useful for showing
trends in data over time and determining whether changes
in rates are the result of specific interventions (special
cause) or normal variation (common cause).
6
Control
charts display variability in performance of a process or
system and allow users to determine when to intervene.
Additional information about control charts can be found
in Carey and Lloyd.
7
Text box 8-2 provides an example of
how one health system uses control charts for monitoring
hand hygiene.
95
chapter 8
DISPLAYING AND INTERPRETING
HAND HYGIENE DATA
FOR MAXIMUM EFFECTIVENESS
ASSOCIATING PROCESS MEASURES OF
HAND HYGIENE WITH THE OUTCOME OF
INFECTION RATES
Some organizations monitor hand hygiene adherence rates
along with health care-associated infection rates. Text Box
8-3 describes one hospital that has done this.
While monitoring infection rates along with the
processes of hand hygiene can be useful, drawing conclu-
sions about both deserves a bit more discussion. A number
of researchers have conducted systematic reviews of the link
between hand hygiene and infection rates. Appendix 8-1
provides examples of studies that examine the relationship
between hand hygiene and infection rates. The updated
WHO guidelines also contain a table that reviews all studies
with significant impact on health care–acquired infections
in campaigns worldwide.
8
While many studies infer a relationship between hand
hygiene practices and infection rates, fewer have identified
96
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Figure 8-1.
Mock Hand Hygiene Dashboard, First Quarter 2008
97
Displaying and Interpreting Hand Hygiene Data for Maximum Effectiveness
Text Box 8-1.
Examples of Data Displays Across Different Levels of Analysis
Park Nicollet Methodist Hospital, St. Louis Park, Minnesota
Park Nicollet Methodist Hospital reports hand hygiene adherence rates over time, according to the observed hand hygiene
opportunities, and by health care worker discipline:
Do we clean our hands when we should?
The overall hand hygiene rate depicted in the following graph shows that the adherence rate was 75% in phase 7; this is an
improvement over Phase 6.
When do we clean our hands?
The following graph shows three specific times when health care workers can do hand hygiene: before patient care, after patient
care, and when patients are in isolation. After significant initial improvement, hand hygiene before patient care continues at a
rate of around 65%.
98
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Text Box 8-1. (continued)
Who cleans their hands?
The following graphs show hand hygiene rates according to professional groups (IV Therapy, Housekeeping, Lab, Nurse,
Nursing Assistant, Physician, Respiratory Therapy, Technicians, Therapists, and Radiology Technicians).
99
Displaying and Interpreting Hand Hygiene Data for Maximum Effectiveness
Text Box 8-1. (continued)
Spartanburg Regional Healthcare System, Spartanburg, South Carolina
Spartanburg Regional Healthcare System reports data stratified by type of health care worker and observed hand hygiene
opportunities (hand hygiene before patient care, hand hygiene after patient care):
OVERALL Compliance by Job Title March–April 2006 (n = 733)
Before: 63.8%
After: 83.6%
a statistical association. According to Larson et al., “the
multi-factorial determinants of who does or does not
acquire an infection under certain circumstances means that
an x percentage increase in handwashing does not necessar-
ily result in a predictable, or even a measurable, reduction
in the risk of infection.”
9(p. 15)
Vandenbroucke-Grauls
describes an association between hand hygiene and infec-
tion rates as “circumstantial.”
10
Nevertheless, the Centers for Disease Control and
Prevention guidelines, WHO guidelines, and several
authors of review articles argue that the evidence for an
association is well established.
3,11
Larson reviewed 423 arti-
cles from 1879 through 1986 and found that most elements
for causality, including temporality, strength, plausibility,
consistency of the association, and dose response, were
present.
12
Stone et al. present a table of nine studies that
demonstrate improved outcomes attributable to hand
hygiene.
13
In a review of the studies from 1977 to 1998,
Larson concludes that, despite some methodological flaws
and data gaps, evidence for a causal relationship between
hand hygiene and reduced transmission of infections is con-
vincing.
14
Larson proposed a four-level scoring tool for
evaluating the quality of the studies published in 2004 that
evaluated interventions to reduce infections.
15
In a recent review article, Backman et al. concluded
that there is a lack of rigorous evidence linking specific hand
hygiene interventions with the prevention of health
care–associated infection, primarily due to the limitations
in studies as classified according to the Larson scoring tool.
16
They propose that different research approaches based on
integrative science and mixed qualitative and quantitative
methods are needed to better understand these relation-
ships.
Several reasons why this link is difficult to establish
conclusively are described in Text Box 8-4.
100
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Text Box 8-2.
System-wide Statistical Process Control Charts
Bellin Health System, an integrated health care delivery system
based in Green Bay, Wisconsin, serves 450,000 people in
northeastern Wisconsin and the Upper Peninsula of Michigan.
Bellin’s commitment to quality improvement began in the late
1980s, when few health care organizations were interested in
quality improvement concepts. Bellin now embraces an
integrated measurement system based on the plan-do-check-act
(PDCA) cycle, using statistical process control (SPC) charts to
track its processes for stability and response to its improvement
initiatives. Bellin uses hundreds of SPC charts to track
performance across multiple locations.
In order to streamline its indicator reports and reporting
process, in 2005 Bellin began using a performance
improvement software system. This system allows easy,
understandable information to be readily accessible on the
organization’s intranet; there are no paper reports and no
waiting for meetings to distribute results. When graphs are
updated, the graph “owners” (department or unit manager and
the quality assurance [QA]/quality improvement [QI]
representative) receive an e-mail alert; at the division level, the
hand hygiene SPC charts go to the infection preventionist and
the vice president. The charts include a definition of each
measure and who to contact for questions. Owners can
annotate the graphs, to note when it mounted alcohol-based
hand rub dispensers outside the patient rooms. One example
of Bellin’s hand hygiene SPC charts is shown here.
101
Displaying and Interpreting Hand Hygiene Data for Maximum Effectiveness
Text Box 8-3.
A Hospital That Correlates Health Care-Associated Infection Rates with Hand
Hygiene Adherence Rates
Jewish Hospital in Cincinnati, Ohio, is a 200-bed suburban teaching hospital that implemented infection prevention care
bundles in its intensive care unit in 2003. Each care bundle includes several infection prevention strategies, including hand
hygiene. Since introducing care bundles, the hospital has reduced ventilator-associated pneumonia, catheter-associated
bloodstream infections, and catheter-associated urinary tract infections. The hospital has also recorded trends in its hand hygiene
observational data over the same period of time. The trend has been an inverse correlation between health care–associated
infections, which have decreased over time, and hand hygiene adherence, which has increased over the same time period (see the
following mock graph of how this might look).
KEY POINTS, CHAPTER 8
• Displaying adherence rates stratified by
groups (units, health care worker
discipline, observed opportunity, and
so on) makes findings easier to interpret
and use.
• Using dashboards and data displays can help
effectively communicate adherence to health
care workers as well as administrators and
board members.
• Data trends over time are useful for
demonstrating ongoing improvements in
adherence.
• Infection rates often decrease with improved
hand hygiene, but causation is difficult to
establish.
102
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Text Box 8-4.
Challenges to Linking Hand Hygiene Practices and Health Care–Associated
Infection Rates
• Large sample sizes are needed to have enough infections for
sufficient power to detect a change in infection rates.
10
• Infection rates demonstrate a great deal of natural
variability, and it is difficult to determine whether
decreases in rates are due to random chance or natural
variability rather than to the intervention.
16
• There are limitations in the study designs used to
investigate the link between hand hygiene and infection
rates. Most studies are uncontrolled, pre- and post-
intervention in single sites. For obvious ethical reasons, it is
not feasible to conduct a randomized controlled trial in
which patients would receive care from clinicians who did
not perform hand hygiene.
10
• Outcomes such as infection rates are affected by numerous
additional factors, including patient age and comorbidities,
number and types of procedures experienced,
organizational factors such as staffing levels, staff training,
and experience, and so on.
• It is difficult to separate the influence of improved hand
hygiene from other factors or interventions designed to
reduce health care–associated infections that are
implemented during the same time frame.
10
Often hand
hygiene is included in intervention “bundles” that address
several aspects of care processes. For example, the Institute
for Healthcare Improvement (IHI) includes hand hygiene
in its bundle related to central line infections. The IHI’s
central line bundle has five key components: hand hygiene,
maximal barrier precautions, chlorhexidine skin antisepsis,
optimal catheter site selection, and daily review of line
necessity (see http://www.ihi.org/nr/rdonlyres/0ad706aa-
0e76-457b-a4b0-78c31a5172d8/0/centrallineinfectionsho
wtoguide.doc).
• The limitations of accurately measuring hand hygiene
adherence using observation or product measurement
(described in previous chapters) make it difficult to
establish causation. Measurement methods have inherent
biases that routinely lead to over- or underestimates of
adherence.
10
• Some infection rates are more likely than others to be
sensitive to changes in hand hygiene. For example,
bloodstream infections and urinary tract infections are
associated with invasive devices that are inserted by staff
and manipulated periodically while the line or catheter is
in place. Surgical site infections may be less sensitive to the
care process because they are more likely to be associated
with practices in the surgical suite.
17
(Larson, et al. 2007).
• Some infections may be due to endogenous flora (normal
and abnormal flora that are carried by the patient upon
admission to the intensive care unit) rather than exogenous
flora (microorganisms introduced into patients from the
intensive care unit environment), which is less affected by
hand hygiene.
18,19
REFERENCES
1. Pugh M., Reinertsen J.L.: Reducing harm to patients. Healthc
Exec 22:62, 64–65, 2007.
2. Donabedian A.: The quality of care: How can it be assessed?
JAMA 260:1743–1748, 1988.
3. World Health Organization (WHO), World Alliance for Patient
Safety: Global Patient Safety Challenge 2005–2006: Clean Care Is
Safer Care. Geneva: WHO, 2006. http://www.who.int/gpsc/en/
(accessed Dec. 5, 2008).
4. Ontario, Canada, Ministry of Health and Long-Term Care: Just
Clean Your Hands. http://www.justcleanyourhands.ca (accessed
Dec. 5, 2008).
5. Clare Barry, B.N., M.S.C., C.I.C, Ministry of Health and Long-
term Care, Ontario, Canada, personal communication, Dec.
2007.
6. Sellick J.A.: The use of statistical process control charts in hospital
epidemiology. In Beyond Infection Control: The New Hospital
Epidemiology, edited by Bryan P. Simmons and Stephen B.
Kritchevsky. Infect Control Hosp Epidemiol 14(11):649–656, 1993.
7. Carey R.G., Lloyd R.C.: Measuring quality improvement in
healthcare: A guide to statistical process control applications.
Milwaukee, WI: American Society for Quality, 2001.
8. World Health Organization (WHO): WHO Guidelines on Hand
Hygiene in Health Care (Advanced Draft): A Summary. Geneva,
Switzerland: WHO, 2006.
9. Larson E.L., et al.: An organizational climate intervention
associated with increased handwashing and decreased nosocomial
infections. Behav Med 26:14–22, Spring 2000.
10. Vandenbroucke-Grauls C.: Clean hands closer to the bedside
(commentary). Lancet 356:1290–1291, Oct. 14, 2000.
11. Boyce J.M., Pittet D.: Guideline for Hand Hygiene In Health-
Care Settings: Recommendations of the Healthcare Infection
Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect
Control Hosp Epidemiol 23(Suppl.):S3–S40, Dec. 2002.
12. Larson E.: A causal link between hand washing and risk of
infection? Examination of the evidence. Infection Control 9:28–36,
Jan. 1988.
13. Stone S., Teare L., Cookson B.: Guiding hands of our teachers
(letter). Lancet 357:479–480, Feb. 10, 2001.
14. Larson E.: Skin hygiene and infection prevention: more of the
same or different approaches? Clin Infect Dis 29:1287–1294,
1999.
15. Larson E. State-of-the-science—2004: Time for a no excuses/no
tolerance (NET) strategy. Am J Infect Control 33:548–557, Nov.
2005.
16. Backman C., Zoutman D.E., Marck P.B.: An integrative review of
the current evidence on the relationship between hand hygiene
interventions and the incidence of health care-Associated
infections. Am J Infect Control 36:333–348, Jun. 2008.
17. Larson E.L., Quiros D., Lin S.X.: Dissemination of the CDC’s
hand hygiene guideline and impact on infection rates. Am J Infect
Control 35:666–675, Dec. 2007.
18. Grundmann H., et al.: How many infections are caused by
patient-to-patient transmission in intensive care units? Crit Care
Med 33:946–951, 2005.
19. Silvestri L., et al.: Handwashing in the intensive care unit: a big
measure with modest effects. J Hosp Infect 59:172–179, 2005.
Displaying and Interpreting Hand Hygiene Data for Maximum Effectiveness
Appendix 8-1.
Examples of Studies That Examine the Association Between Hand Hygiene
Performance and Infection Rates
Findings and comments
Significant improvement in
hand hygiene (HH) adherence
was not associated with
detectable changes in health
care–associated infection (HAI)
incidence.
Researchers found an increase in
HH adherence over time, but
there was no correlation
between transmission rates of
health care–associated
pathogens, hand rub
consumption, or observed HH
adherence.
Methods
Two-year prospective controlled
crossover trial of alcohol-based
hand rub (ABHR) gel.
Primary outcome was incidence
of transmission of 10 most
frequent pathogens using “gold
standard” genotyping methods;
observed HH adherence, and
measured product consumption;
18 months.
Study
Rupp M.E., et al.: Prospective,
controlled, cross-over trial of
alcohol-based hand gel in
critical care units. Infect Control
Hosp Epidemiol 29:8–15, Jan.
2008.
Eckmanns T., et al.: Hand rub
consumption and hand hygiene
compliance are not indicators of
pathogen transmission in
intensive care units. J Hosp
Infect 63:406–411, Aug. 2006.
Setting
Two 12-bed medical
intensive care units
(MICUs) at a single
hospital in Nebraska.
Five intensive care units
(ICUs) at two university
hospitals in Europe.
103
104
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Appendix 8-1. (continued)
Researchers found 85% relative
reduction of VRE rate in the
intervention hospital and 44%
in control hospital. VRE rates
decreased significantly in both
hospitals but were more
significant in the intervention
hospital. Rates of MRSA were
not significantly different
between hospitals.
Researchers found significant
improvement in observed HH
adherence as well as
consumption of ABHR, which
coincided with overall HAI rate
decreases from 16.9% to 9.9%
and MRSA transmission rates
falling from 2.16 episodes per
10,000 to 0.93 episodes.
Improving HH from 42% to
55% was associated with a 60%
decrease in the risk of HAI in
very low birthweight newborns;
a 9-month follow-up showed
sustained improvement in HH.
Significantly lower rates of HAIs
were noted when a
chlorhexidine hand disinfection
system was used than one using
alcohol and soap.
Improved adherence with HH
was associated with
nonsignificant trends (due to
low statistical power) toward
lower HAI rates.
Eight-month quasi-experimental
intervention trial to assess the
impact of an intervention to
change organizational culture on
frequency of hand hygiene and
HAIs, methicillin-resistant
Staphylococcus aureus (MRSA),
and vancomycin-resistant
enterococci (VRE).
Implemented a multimodal HH
campaign with promotion of
bedside antiseptic hand rubs.
Measures included seven
observation periods with
> 20,000 opportunities across
four years and hand rub
consumption.
18-month multifaceted
education program guided by
worker perceptions with
performance feedback and care
procedure reorganization;
observation measurement with
genotyping of bloodstream
pathogens; also product volume
measurement.
Eight-month prospective
multiple crossover trial.
Electronic voice prompts as
intervention when failure to
perform HH; pre and post
electronic monitoring sink and
ABHR dispensers with entry
and exit into room; education.
Larson E.L., et al.: An
organizational climate
intervention associated with
increased handwashing and
decreased nosocomial infections.
Behav Med 26:14–22, Spring
2000.
Pittet D., et al.: Effectiveness of
a hospital-wide programme to
improve compliance with hand
hygiene. Lancet
356:1307–1312, Oct. 14, 2000.
Errata in: Lancet 356:2196,
Dec. 13–20, 2000.
Pessoa-Silva C.L., et al.:
Reduction of health care
associated infection risk in
neonates by successful hand
hygiene promotion. Pediatrics
120:e382–e390, Aug. 2007.
Doebbeling B.N., et al.:
Comparative efficacy of
alternative hand-washing agents
in reducing nosocomial infections
in intensive care units. N Engl J
Med 327:88–93, Jul. 9, 1992.
Swoboda S.M., et al.: Electronic
monitoring and voice prompts
improve hand hygiene and
decrease nosocomial infections
in an intermediate care unit.
Crit Care Med 32:358–363,
Feb. 2004.
Four ICUs within two
hospitals in the Mid-
Atlantic region of the
United States.
One large teaching
hospital in Switzerland.
Neonatal intensive care
unit (NICU) in a
children’s hospital in
Switzerland.
Three ICUs within one
large teaching hospital.
14-bed intermediate
care unit in teaching
hospital.
Study Setting Methods Findings and comments
105
Displaying and Interpreting Hand Hygiene Data for Maximum Effectiveness
Appendix 8-1. (continued)
Greater rates of HH occurred
when patients were in
designated isolation rooms;
however, patients in isolation
rooms also had higher rates of
infection.
Adherence with HH increased
from 23% before interventions
to 65% after. During the same
period, overall HAIs in the
ICUs decreased significantly,
from 48 per 1,000 patient days
to 28 per 1,000 patient days.
Improved adherence with HH
was associated with a significant
decrease in overall rates of HAIs,
particularly respiratory
infections.
HH improved following an
interventional period, and HAIs
decreased from 11.3 to 6.2 per
1,000 patient days.
A significant overall reduction in
infection rates of 30% was
found in units that used the
hand sanitizers compared to
units that did not.
Prospective three-phase
electronic measurement of HH
rates using product
measurement with automated
voice message reminders.
19-month education and
performance feedback
intervention, with observation
of HH twice each week;
included efforts to promote
guideline adherence for
bloodstream infection and
urinary tract infection.
23-month multimodal
campaign education, reminders,
incentives, and feedback; covert
observation.
HH education and a problem-
based task-oriented protocol
emphasizing minimal handling
and clustering of nursing care
procedures; unobtrusive
observer.
Alcohol gel hand sanitizer
introduced, and infection rates
monitored for 34 months.
Swoboda S.M., et al.: Isolation
status and voice prompts
improve hand hygiene. Am J
Infect Control 35:470–476, Sep.
2007.
Rosenthal V.D., Guzman S.,
Safdar N.: Reduction in
nosocomial infection with
improved hand hygiene in
intensive care units of a tertiary
care hospital in Argentina. Am J
Infect Control 33:392–397, Sep.
2005.
Won S.P., et al.: Handwashing
program for the prevention of
nosocomial infections in a
neonatal intensive care unit.
Infect Control Hosp Epidemiol
25:742–746, Sep. 2004.
Lam B.C., Lee J., Lau Y.L.:
Hand hygiene practices in a
neonatal intensive care unit: A
multimodal intervention and
impact on nosocomial infection.
Pediatrics 114:e565–e571, Nov.
2004.
Fendler E.J., et al.: The impact
of alcohol hand sanitizer use on
infection rates in an extended
care facility. Am J Infect Control
30:226–233, Jun. 2002.
Intermediate care unit
of one hospital (three
isolation and six non-
isolation rooms).
Two ICUs (one surgical
intensive care unit and
one CCU) in one
hospital in Argentina.
One level III NICU in
a Taiwan teaching
hospital.
One 12-bed NICU in a
Hong Kong university
hospital.
Two units of a 375-bed
extended care facility.
Study Setting Methods Findings and comments
“Sometimes, the step from best evidence to best practice is simple;
however, most of the time it is not, and we need various strategies
targeting obstacles to change at different levels, which could even
present conflicting values for individual practitioners.”
1(pg1228)
The purpose of this chapter is to introduce the strate-
gies and challenges associated with implementing successful
interventions to improve hand hygiene practice in health
care organizations. It also provides examples of the funda-
mental linkage between measurement and improvement
activities. Sources for additional information and improve-
ment tools are provided in Chapter 10.
COMPLEXITY OF CHANGING BEHAVIOR
As valuable as guidelines are for identifying and recom-
mending evidence-based practices for improving quality
and reducing inappropriate variation in care, they are some-
times ineffective in directly changing behavior. For
example, Larson et al.
2
studied the diffusion, implementa-
tion, and impact of the revised Centers for Disease Control
and Prevention (CDC) hand hygiene guidelines
3
on prac-
tice in 40 National Nosocomial Infections Surveillance
system hospitals. They found that hospital staff were well
aware of the guidelines and that structural changes had been
made to implement new policies and ensure that products
were available to staff. However, there was no difference in
the process of hand hygiene or the outcome of infection
rates when comparing hospitals with high and low guideline
implementation scores. The researchers concluded that dis-
semination of the guidelines was insufficient to effect
change in clinician practice. To improve hand hygiene
adherence, a comprehensive, multidisciplinary effort that
includes explicit support from administration is needed.
Effective Models and Strategies for Hand
Hygiene Behavior Change
Many have had the experience of implementing new pro-
grams or systems to improve hand hygiene, only to find
little change in adherence rates or improvements that were
not sustained when the focused attention on hand hygiene
was removed. In part, this is because the science of quality
improvement is not sufficiently developed to establish
which interventions work best under what specific circum-
stances and settings.
1
As Grol and Grimshaw point out,
there are many different, and sometimes competing,
approaches to changing practice, all of which claim to be
effective.
1
Experts suggest that interventions often fail to improve
staff practice because they are not customized to specific
problem areas within an organization. Sometimes interven-
tions that work well in one organization will not work well
in other organizations. This variation highlights the need to
thoroughly investigate the underlying causes of the problem
as well as identify local obstacles to improvement. Then you
can tailor your improvement intervention to your facility or
special setting-specific needs.
Before implementing improvement strategies, it is
useful to explicitly consider why and how a particular strat-
egy should work.
4
Implementing change often starts with a
conceptual framework based on a theoretical model for
107
chapter 9
MEASUREMENT IS ONLY THE
BEGINNING: FACTORS THAT
CONTRIBUTE TO IMPROVEMENT
behavior change.
5
A widely used theoretical model for
explaining motivation to perform hand hygiene is the
Theory of Planned Behavior.
6–8
This theory postulates that
one can predict an individual’s intention to perform a
behavior by that person’s attitude and beliefs, perception of
social pressure to perform the behavior (subjective norm),
and perceived level of control (ease or difficulty) in per-
forming that behavior.
9
Whitby et al. applied the Theory of
Planned Behavior in a study of 754 nurses.
10
They found
that hand hygiene behavior fell into two broad categories:
inherent, which is an intrinsic self-protective behavior that
occurs when hands are visibly soiled or sticky, and elective
behavior, which is driven more by social norms, such as
handwashing before eating and before patient care or
contact with the environment. Whitby et al. argue that
efforts to increase elective hand hygiene behavior through
structural interventions such as improving access to hand
rub will have limited success without a concomitant behav-
ioral modification component.
Grol and Grimshaw, in their review of the effectiveness
of strategies for changing behavior, describe several different
behavior change theories that are applicable to improving
hand hygiene (Table 9.1).
1
Maskerine and Loeb suggest that
the approach based on the health belief model and the
theory of reasoned action, along with behavioral reinforce-
ment, may be the most likely to succeed.
11
Ideally, the
behavior change model should be explicitly stated because it
drives the selection of improvement strategies and allows
others to make informed choices about what works best in
different settings.
12,13
FACTORS THAT AFFECT THE SUCCESS OF
IMPROVEMENT INITIATIVES
Many internal and external factors influence the success of
a hand hygiene improvement initiative. These factors can be
grouped into five categories:
• Use of effective strategies
• Organizational and system characteristics
108
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Table 9-1.
Examples of Theoretical Models and Improvement Strategies for Behavior Change
in Hand Hygiene
Theoretical Model
Cognitive
Behavioral
Social Influence
Marketing
Organizational
Explanation for Low Adherence
Lack of knowledge of the results of poor hygiene and the
evidence base
Behavior is mainly influenced by external stimuli; more are
needed to change behavior
Absence of social norms promoting hand hygiene; lack of
leadership
Important to have clear and attractive message tailored to
target audience
Problem is system failure not individual practitioner
Strategies for Improvement
Associated with the Model
Education; solutions identified
through discussion of barriers
Reminders, feedback, incentives,
modeling, and external reinforcement
Local consensus, opinion leaders, role
models setting examples
Mass media campaigns, academic
detailing
Quality improvement teams, redesign
processes, workload, promoting safety-
oriented culture
Source: Adapted from Grol R., Grimshaw J.: From best evidence to best practice: Effective implementation of change in patients’
care. Lancet 362:1225–1230, 2003.
• Personnel
• Involvement of patients and families
• External environment
These factors and their underlying components are dis-
played in Figure 9-1 and are discussed in detail throughout
the rest of this chapter.
Before you implement change, you should ensure that
you have an accurate assessment of your current state of
hand hygiene practice. As stated in Ontario’s A Quick Guide
to Just Clean Your Hands, “Good data can close the gap
between perception and practice.”
14(p. 4)
Much as a physician
diagnoses a patient, you need to be reasonably confident
about what the problem is before you decide on a treat-
ment. Accurate assessment can minimize both the risk of
falsely concluding that there is no problem when there
really is one and unnecessarily tampering with processes
that are actually performing well.
Use of Effective Strategies
It is important to select and implement effective interven-
tions. The following are five examples of widely used
intervention strategies for hand hygiene initiatives:
• Education and training
• Audit and feedback
• Reminders
• Use of multidisciplinary teams
• Systematic performance improvement methods
109
Measurement Is Only the Beginning: Factors That Contribute to Improvement
Figure 9-1.
Factors Affecting the Success of Hand Hygiene Improvement Initiatives*
* hh, hand hygiene.
Education and Training
Researchers have found that many health care workers do
not have a clear understanding of the opportunities for
hand hygiene.
14–16
While most staff believe that they are suf-
ficiently knowledgeable about hand hygiene, training staff
on the specific indications for hand hygiene can increase
their awareness of the complexity of the indications and
make them more sensitive to non-adherence.
Because you may have a wide range of intended audi-
ences, the level and amount of education and training that
you provide should be tailored to each audience. Education
and training should be easy to understand, culturally appro-
priate, and conducted in languages other than English, as
necessary.
Audit and Feedback
Systematic literature reviews have shown that audits (also
known as periodic performance measurement) followed by
comparative feedback on performance, are generally effec-
tive for stimulating improvement at both the provider and
organizational levels, particularly when baseline levels of
performance are low.
17,18
The WHO guidelines consider
audit and feedback of adherence data to be an essential
element of multimodal strategies to improve hand hygiene
practice.
19,20
Feedback can be unit specific, practitioner spe-
cific, or both, and it can be reported confidentially or
publicly.
Numerous studies have demonstrated improvement in
adherence rates after audit and feedback. However, one
study found that the influence of live observers had a greater
impact on hand-washing behavior than sustained feedback
of unit-level adherence rates.
21
Reminders
Visual or auditory reminders are popular and effective
strategies for improvement. Grol and Grimshaw reviewed
the literature for interventions focused on improving hand
hygiene and found that reminders had a modest but sus-
tained impact on hand hygiene practices in the seven
studies.
1
Examples of reminders include posters and brightly
colored signs, eye-catching screen savers, e-mail messages,
voice mail messages, labels on equipment and supplies
(including patient gowns), campaign buttons, and “talking
walls.”
22
Ontario’s “Just Clean Your Hands” program encourages
the use of reminders; “the visuals are designed to support
and maintain healthcare providers’ awareness of hand
hygiene issues, as well as the importance of adherence.
Posters and other support materials in a consistent visual
style are valuable ways of supporting and reinforcing key
messages and behavior change when used as part of a multi-
faceted strategy.”
23
Samples of their “reminders” can be
found at http://www.justcleanyourhands.ca/reminders_
in_the_workplace.php. Using multiple reminders and
changing signs periodically helps to maintain attention to
hand hygiene.
Use of Multidisciplinary Teams
Most systematic quality improvement models recommend
using multidisciplinary teams to analyze and improve hand
hygiene processes. The Institute for Healthcare
Improvement (IHI) recommends that improvement teams
be “heterogeneous in make-up but unified in mindset.”
24
It
is important to include all stakeholders in the process to
gain buy-in and cooperation. Each member of the care team
should have a stake in the outcome, and all the members
should work together to achieve the common goal.
24
The
IHI recommends that, at a minimum, such a team should
include an administrator or a senior leader who can help
remove barriers to implementation and someone from the
department that supplies hand hygiene agents to clinical
areas. The team should comprise individuals who want to
be on the team rather than those who do not, and the team
should also include clinical champions and opinion leaders
within the organization to enhance the credibility of the
improvement effort.
The CDC and WHO hand hygiene guidelines also rec-
ommend use of a multidisciplinary program to improve
adherence.
3,19
Nevertheless, there is evidence that the team
approach is not being used as often as it should be. Larson
et al. found that fewer than 20 of 40 National Nosocomial
Infection Surveillance System hospitals had actually imple-
mented multidisciplinary programs for improving hand
hygiene.
7
110
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Systematic Performance Improvement Methods
Use of a systematic quality improvement model adds
structure and rigor to your improvement efforts.
Common elements of most structured approaches include
the following:
• Establishing goals
• Measuring performance
• Investigating causes and contributing factors
• Analyzing current processes using a team approach
• Implementing changes using a gradual, staged
approach
• Evaluating the short- and long-term impact of
interventions
Well-known examples of sustained, structured quality
improvement models include the following:
• The plan-do-study-act (PDSA) rapid cycle
improvement (for additional information see
http://www.ihi.org/IHI/Topics/Improvement/Improve
mentMethods/HowToImprove/)
• Six Sigma
25–27
• Clinical Microsystems
28
Many of the tools incorporated in structured quality
improvement models are useful for understanding reasons
for non-adherence to guidelines and identifying and priori-
tizing strategies for improvement. Examples of these tools
include fishbone, or Ishikawa, diagrams; flowcharting of
processes; multivoting and nominal group techniques; and
statistical process control charts.
Text Box 9-1 provides two examples of organizations
that used systematic approaches to improve health care
worker hand hygiene adherence.
Other Strategies
In addition to the systematic approaches described so far,
some less-well-known improvement strategies may be effec-
tive in improving hand hygiene. These include the use of
local opinion leaders, academic detailing, and positive
deviance. Local opinion leaders are persons considered by
their colleagues or peers to be educationally influential in
influencing behavior or implementing change.
30
They are
distinct from role models in that they need not come from
the same discipline or provider group. Academic detailing,
also known as educational outreach visits, involves using a
trained person to meet with providers in their practice set-
tings to give information, with the intent of changing the
provider’s practice.
30,31
Positive deviance is a culturally appropriate improve-
ment approach based on the notion that in every
community, there are certain individuals (the “positive
deviants”) whose special practices/strategies/behaviors
enable them to find better solutions to prevalent commu-
nity problems than their neighbors who have access to the
same resources.
32
Gawande describes the successful use of
positive deviance for reducing infection rates in a VA hospi-
tal in Pittsburgh. In brief, staff from a wide variety of
disciplines and levels were systematically engaged in identi-
fying and applying creative approaches to preventing
infection, which led to a dramatic reduction in methicillin-
resistant Staphylococcus aureus (MRSA) transmission rates
over time.
33
Organizational and System Characteristics
In order to put into place structures and processes that facil-
itate hand hygiene, it is necessary to understand the
organizational systems and environment in which health
care providers work.
Structural Capacity
The organization should provide easy, convenient access to
hand hygiene products, gloves, lotions, sinks, and the like
and should ensure that staff are satisfied with the products
used.
19
Many initiatives have found that putting supplies
such as alcohol-based hand rub at the point of care
improves hand hygiene. According to Ontario’s A Quick
Guide to Just Clean Your Hands, point of care means that
three elements are present simultaneously: the patient, the
health care provider, and care that involves patient contact.
14
Policies, Procedures, and Processes
Organizations should have written policies and procedures
in place that describe when and how staff are expected to
perform hand hygiene and how staff are to be educated and
111
Measurement Is Only the Beginning: Factors That Contribute to Improvement
trained. Policies should be developed by a multidisciplinary
team that includes the organization’s leadership, safety per-
sonnel, environmental services staff, and staff from various
departments, and should be widely disseminated across the
organization.
To reduce the number of hand hygiene opportunities
within an episode of care, some organizations have begun to
examine ways to simplify their care processes. For example,
an effort to minimize handling and to cluster nursing pro-
cedures in a neonatal intensive care unit (NICU) reduced
the total number of patient contact episodes from 2.8 per
patient per hour to 1.8 per patient per hour.
34
When this
effort was combined with improved access to alcohol-based
hand rub, audit, and feedback, the NICU observed a sub-
stantial decrease in health care–associated infection rates.
112
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Text Box 9-1.
Using Systematic Approaches for Improving Hand Hygiene
Managing Toward Daily Compliance
The Cleveland Clinic in Cleveland, Ohio, launched an
initiative to improve hand hygiene that began in the oncology
unit in June 2007. The goal was to increase hand hygiene
adherence from the baseline rate of 24% to a sustained rate of
greater than 85%.
Demonstrating that short-term data collection and rapid
feedback can have a big impact on hand hygiene performance,
staff introduced the “Managing Toward Daily Compliance”
methodology, a quick-cycle method of observing practices and
reacting to successes and non-adherence. The objective of
“Managing Toward Daily Compliance” is daily management of
all groups of health care workers toward adherence to standard
operating procedures, and it is accomplished through a
multidisciplinary team on a selected unit.
Staff use a rapid-cycle approach from the Institute for
Healthcare Improvement (IHI) along with strategies and tools
from Six Sigma in their improvement efforts. They launched
an awareness campaign that includes health care worker
education, chief executive officer messages, and placement of
alcohol-based hand rub dispensers inside and outside patient
rooms. The team is led by the unit’s nurse manager, and team
members include nurses, medical staff members, and staff from
radiology, food services, environmental services, patient
transportation, phlebotomy, and respiratory therapy.
Each team member observes at least five episodes of hand
hygiene daily, and meets briefly (“huddles”) with other team
members the following day to share results; results are recorded
on a board, with the names of the observed individuals
included, if available. Each team member provides feedback to
his or her respective area. When staff reach their adherence
goal and sustain it for at least one week, the frequency of
huddles decreases. However, anytime adherence falls below
85%, daily huddles resume. Adherence increased to 94%
within five weeks of implementing the “Managing Toward
Daily Compliance” initiative, with an average of 180
observations collected by the team each week. Ongoing
adherence has remained above 85%, and the project has been
expanded to four additional units with similar success.
Source: Weber MM, et al.: Using Managing Towards Daily
Compliance Methodology as a Pilot to Improve Hand Hygiene on
an Oncology Nursing Unit. Society for Healthcare Epidemiology
of America annual meeting, Orlando, FL, April, 2008.
Using Six Sigma Methods
The Six Sigma process was an effective strategy for organizing
knowledge, opinions, and actions to improve staff adherence
to the Centers for Disease Control and Prevention (CDC)
hand hygiene guidelines in four intensive care units at three
Department of Veterans Affairs (VA) medical centers,
according to Eldridge et al.
29
Beginning in 2003, they
systematically applied the five phases of Six Sigma known as
DMAIC (Define, Measure, Analyze, Improve, Control). In the
Define (D) phase, they developed a project charter agreed
upon by all participants. In the Measure (M) phase, they
developed a process map, used a cause-and-effect matrix, and
measured baseline performance by observation and by tracking
grams of alcohol-based hand rub used. They also measured
intensive care unit (ICU) staff attitudes and perceptions and
conducted a hand assessment. In the Analyze (A) phase, they
utilized failure mode and effects analysis and analyzed
performance data. The Improve (I) phase involved adjusting
processes, and the Control phase (C) involved remeasurement
to determine whether gains were sustained. The success was
demonstrated by the fact that the observed hand hygiene
adherence rate went from 47% to 80% by late 2004, based on
analysis of more than 4,000 observations. The rate of use of
alcohol-based hand rub product (expressed in grams per
patient day) also increased demonstrably in the three different
ICUs that were able to measure this parameter.
Leadership
With most improvement initiatives, the commitment of an
organization’s leadership is one of the factors that ultimately
has the greatest impact on success. Leadership should be
defined broadly to include not only the organization’s exec-
utives, officers, and directors but also the clinical staff
leaders in each area and the leaders of teams and improve-
ment initiatives. Larson reports that senior management
commitment to administrative and system change is essen-
tial to achieving and sustaining reductions in infection
rates.
35
Rosenthal et al. also found that administrative
support played an important role in the improvement of
hand hygiene adherence.
36
Administration Leaders
Administration determines resources available for hand
hygiene measurement and improvement, including ade-
quate infection prevention and control staff, resources for
education, and the like. In addition, administration leaders
do the following:
• Set expectations for the staff and for the board (for
example, by determining organizational priorities and
the level of the organization’s focus on hand hygiene)
• Motivate staff through leading by example both in
performing hand hygiene and by participating in
performance improvement initiatives (see Text Box 9-
2 for an example of visible commitment)
• Remove structural barriers (for example, by providing
for the installation of dispensers and the purchase of
individual bottles of alcohol-based hand rub to
eliminate problems associated with inconvenient
access to products)
• Establish accountability (as described later in this
chapter)
• Celebrate successes throughout the organization and
within departments
Clinical Leaders: The Importance of Role Models
Research in many areas of health care has found that if role
models don’t demonstrate the preferred behavior, others will
not either. Lankford et al. assessed the effect of medical staff
role models on hand hygiene practice and found that health
care workers in a room with a higher-ranking medical staff
member or peer who did not wash hands were significantly
less inclined to wash their own hands.
37
Snow et al. studied
student nursing assistants to determine the effect of hand
hygiene practices on students during clinical rotations and
found the mentor’s hand hygiene practices to be the
strongest predictor of student hand hygiene.
38
Pittet and
Boyce noted in their review of the literature that a lack of
role modeling from superiors or peers was a barrier to
appropriate hand hygiene.
16
In the United Kingdom, junior
doctors have been noted to wash their hands more often
when consultants set the example in performing hand
hygiene.
39
According to the Ontario’s A Quick Guide to Just Clean
Your Hands, “Leadership and hospital-wide commitment to
113
Measurement Is Only the Beginning: Factors That Contribute to Improvement
Text Box 9-2.
An Example of Visible Commitment
St. Joseph Hospital in Lexington, Kentucky, has an
executive team that conducts patient rounds once per
quarter, during which the team members use scripted
questions to ask patients about the hand hygiene practices
of health care workers. The executive team also observes
staff to make sure they are practicing hand hygiene when
they should. Results of the executive rounds are
communicated to leaders for staff commendations and
notification of opportunities for improvement. The hospital
uses the following poster, showing a picture of the chief
executive officer, to encourage hand hygiene.
hand hygiene—with visible role models—is key to
success.”
14(p. 3)
Pittet and colleagues undertook a study of
factors associated with hand hygiene non-adherence among
physicians; they found that adherence was associated with
the belief of being a role model for other colleagues as well
as the awareness of being observed, easy access to cleansing
solutions, and a positive attitude toward hand hygiene.
40
Accountability
Chronically non-adherent staff may need oversight, with
possible disciplinary action, to motivate changes in behav-
ior. Some organizations hold managers and staff directly
accountable for hand hygiene performance and tie perform-
ance to merit increases. Text Box 9-3 provides examples of
organizations that have processes in place to address hand
hygiene adherence.
Leaders of the Improvement Initiative
Leaders of the hand hygiene improvement initiative should
have the requisite knowledge, training, and skills to increase
the likelihood of success. This includes familiarity with per-
formance improvement tools as well as strong
organizational and interpersonal skills. It may be helpful to
designate one person to be accountable for implementing
change and to give that person authority across disciplines,
including physicians, and to provide that person with the
resources needed to improve hand hygiene performance.
Safety Culture
Safety culture and culture of safety refer to an organization’s
commitment to safety that is evident at all levels and that
permeates the entire organization, from frontline personnel
to executive management. Characteristics of organizations
with a safety culture have been identified in studies of
health care organizations
42–44
and in fields outside health
care with exemplary performance with respect to safety.
45,46
Some of these characteristics include the following:
• Acknowledgment of the high-risk, error-prone nature
of an organization’s activities
• A blame-free environment where individuals are able
to report errors or near misses without fear of
reprimand or punishment
• An expectation of collaboration across ranks to seek
solutions to vulnerabilities
• A willingness on the part of the organization to direct
resources for addressing safety concerns
47
To improve hand hygiene performance, it is particularly
important to promote a culture that empowers staff to
speak up when non-adherence is observed. While changing
organizational culture can take years, culture is not neces-
sarily homogenous throughout the organization. It should
be possible to demonstrate measurable changes in culture
within specific departments or units over time. In a recent
multicenter trial, Sinkowitz-Cochran et al. found that per-
ceptions of organizational culture were strongly associated
with perceptions of the benefit of hand hygiene and actual
hand hygiene practices.
48
Leaders must establish a safety-oriented culture, and it
is possible to target hand hygiene interventions toward lead-
ership to promote culture change. Larson et al. studied the
effectiveness of an intervention to change organizational
culture on the frequency of staff hand washing and infec-
tion rates.
49
Top management and medical and nursing
leaders were enlisted to provide active support for culture
change and to engage the implementation managers in the
development of specific elements of the intervention. In
comparison to the control hospital, the intervention site
experienced a significant and sustained increase in the fre-
quency of hand washing, with a concomitant reduction in
rates of vancomycin-resistant enterococci (VRE) and
MRSA.
Personnel
Do you and your team understand which personnel have
direct contact with the patient or the environment across
the organization? Do staff demonstrate proper hand
hygiene technique? Do staff believe that hand hygiene
adherence is important for reducing infections? When do
staff think they should wash their hands? Are people dis-
satisfied with the choice of alcohol-based hand rub or
lotion, and do they resist using it? As Chapter 5 notes,
there are a variety of surveys to assess staff knowledge
about hand hygiene guidelines, staff attitudes toward
114
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
hand hygiene, and staff satisfaction with products.
Experts find that improvement works best when staff are
ready for it.
5
Staff Engagement
It is important to directly engage staff in a hand hygiene
improvement initiative. Rather than dictate changes in
behavior, you should have staff identify obstacles and solu-
tions. Convene focus groups before and during interventions
to identify obstacles to adherence. This type of staff engage-
ment can be helpful in identifying remediable factors,
obtaining staff buy-in, and improving adherence rates.
Incentives and Rewards
One way to engage staff in performance improvement is to
use incentives and rewards. Text Box 9-4 presents examples
from three organizations that have developed creative ways
to motivate staff.
Involvement of Patients and Families
Through the “Partners in Your Care” program, many organ-
izations have educated and engaged patients and families to
remind staff to wash their hands.
50–53
Patient empowerment
is being evaluated in a variety of countries as part of the
WHO initiative (described in Chapter 7) using Web-based
115
Measurement Is Only the Beginning: Factors That Contribute to Improvement
Text Box 9-3.
Accountability of Staff for Hand Hygiene Performance
The multihospital Moses Cone Health System is
headquartered in Greensboro, North Carolina. When the usual
hand hygiene promotional efforts (staff education about hand
hygiene, posters, increased availability of alcohol-based hand
rub, and so on) did not improve hand hygiene adherence rates
from the usual 35% to 40%, Moses Cone created a program
in which individuals who do not perform proper hand hygiene
receive “tickets.” A copy of the ticket is sent to the person’s
director, manager, or department head, and another copy is
sent to the infection prevention department. Additional
education is provided with each ticket, and consequences
increase (for example, verbal warnings, written warnings,
letters from the peer review committee, culminating in
possible termination after five tickets). All physicians, clinical
staff, nonclinical staff, and even contracted staff and volunteers
are included in the program. This process, together with
several other improvement strategies, resulted in a drop in the
number of methicillin-resistant Staphylococcus aureus (MRSA)
infections from 9 per 1,000 patient days to 0.49 per 1,000
patient days.
41
Greenview Regional Hospital in Bowling Green, Kentucky, is a
211-bed hospital that experienced a MRSA outbreak that
began in 2002 and continued into 2003, despite standard
infection control interventions and education; additional
outbreaks occurred in 2004. When direct observation of hand
hygiene practices among hospital staff and physicians revealed
poor hand hygiene adherence (less than 5% across all staff and
physicians), the hospital’s infection preventionist began doing
10- to 15-minute direct observations among all patient care
departments and shifts, with reporting of monthly adherence
rates.
Non-adherent health care workers were identified and
verbally informed when appropriate and reasonable; non-
adherence was also reported to nursing/department managers.
Managers were required to complete action plans for non-
adherence, and these plans were to be sent to human resources.
Hospital administration was informed if managers did not
complete action plans. Standard human resources and hospital
policies were followed for those who continued to be non-
adherent.
Non-adherent physicians were observed without initial
verbal intervention and were allowed three observations of
non-adherence every six months. Physicians reaching the third
observed episode of non-adherence were given a series of
letters: the first to the physician directly; the second to the
physician and to his or her department chair; and the third to
the physician, the department chair, and the credentials
committee. Further action with regard to any continued
physician non-adherence was the responsibility of the
credentials or executive committee, according to the medical
staff by-laws.
By 2005, hand hygiene had improved from the 2003–2004
baseline of 4% among health care workers to 85% and from
2% among medical staff members to 95%. The organization’s
MRSA outbreaks resolved as a result of the accountability for
hand hygiene and ownership of this process, from nursing
mangers, administration, and medical staff leadership.
surveys. Preliminary results indicate that patient involve-
ment may be a useful adjunct to other improvement
activities.
54
A potential modification to the England and Wales
“cleanyourhands” campaign
55
(as described in Chapter 7),
which involves giving patients a bottle of alcohol-based
hand rub to use as a prompt for health care workers, is being
evaluated as part of the “It’s OK to Ask” feasibility study.
The eight-week study involved talking with infection
control teams at each of five participating trusts and con-
ducting surveys with inpatients and members of the public
within each trust.
Patients and visitors appreciate knowing that a health
care setting emphasizes hand hygiene. There is evidence that
patients become more confident about the care they receive
when they see that the organization has a commitment to
good hand hygiene.
14
As explained in Chapter 5, you might
want to consider monitoring patient satisfaction with hand
hygiene, especially in patient populations capable of
responding to surveys, such as the outpatient setting.
Because patients and families frequently do not have a
clear understanding of the opportunities for hand hygiene,
education is often needed. Text Box 9-5 contains examples
of how patients and families can be educated regarding
hand hygiene.
Several of the resources and toolkits described in
Chapter 10 include educational materials targeted to
patients.
It is important to note that involving patients is not the
same as relying on patients to change provider behavior. You
should be careful to avoid shifting the burden for monitor-
ing and improvement to those who are sick and vulnerable.
Asking patients to remind staff about performing hand
hygiene has been criticized by some experts, who argue that
hand hygiene is a fundamental ethical responsibility of all
health care workers.
56,57
These experts also suggest that
patients should not be expected to confront health care
workers about non-adherence because they could be subject
to retaliation. Pittet and Perneger point out that hand
hygiene is required in many situations aside from “before
patient contact,” that hand hygiene adherence is generally
worse among physicians than among other care providers,
and that patients may feel too intimidated by physicians to
ask them whether they’ve washed their hands.
58
In addition,
health care workers may not be receptive to being reminded
by patients to perform hand hygiene. If you decide to
engage patients in your hand hygiene improvement efforts,
consider involving them in a way that clearly avoids trans-
ferring responsibility from health care workers to patients or
visitors.
14
External Environment
Groups external to a health care organization often add
increased demands for infection prevention that directly
and indirectly affect hand hygiene adherence. Though
external demands often increase workload, they can facili-
tate local improvement by capturing leaders’ attention and
potentially adding resources and measurement systems. The
following examples of external initiatives support increased
focus on hand hygiene.
Consumer groups demand, and many states and coun-
tries require, public reporting of health care–associated
infections, including catheter-associated bloodstream infec-
tions and urinary tract infections.
59
Medicare and other
insurers have begun to prohibit payment for hospital-
acquired conditions, including selected health
care–associated infections.
60
Accrediting bodies such as The
Joint Commission and the National Committee for Quality
Assurance require compliance with hand hygiene guidelines
and reporting of indicators related to infection prevention.
State inspections for licensure and federal Medicare and
Medicaid certification include assessment of infection pre-
vention activities. These and other initiatives put pressure
on health care organization leadership to ensure that hand
hygiene is being performed effectively.
WHAT IS SUCCESS?
Defining specific, measurable goals for improvement is an
integral part of most structured approaches. Yet, without a
national benchmark, it is difficult to know what an appro-
priate goal is. The Ontario “Just Clean Your Hands”
initiative defines success as “a steady improvement in com-
pliance rates.”
14(p. 10)
Improving hand hygiene involves
changing a habit, and it takes time to obtain a sustained
116
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
117
Measurement Is Only the Beginning: Factors That Contribute to Improvement
Text Box 9-4.
Examples of Staff Incentives and Rewards
The Denver Health and Hospital Authority in Denver,
Colorado, established a positive reinforcement program that
promotes staff hand hygiene adherence. In 2007, the infection
control and patient quality and safety departments, along with
the department of public relations, began a new campaign to
keep hand hygiene in the forefront of staff awareness. This
reinforced a 2006 campaign that consisted of humorous
reminders at every alcohol-based hand rub dispenser and
signage encouraging patient involvement that were placed in
all patient rooms and exam rooms.
Each health care worker who is “caught” performing hand
hygiene before and after patient care is given a reward ticket.
All health care workers who touch patients as part of their job
duties are eligible. Each month’s raffle ticket is a different color
and is associated with a monthly prize. Eligible health care
workers write their contact information on the backs of the
tickets and drop them into labeled ballot boxes located
throughout the patient care areas. Each month the boxes are
emptied, and hospital leaders gather to preside over the
drawing. The winner receives a prize such as a digital camera, a
$300 gas card or gift certificate, ski passes, or athletic game
tickets. In addition, the winner is highlighted in the hospital’s
monthly newsletter.
Spartanburg Regional Healthcare System in Spartanburg,
South Carolina, uses several different approaches to encourage
optimal hand hygiene by staff:
Replacing the “clinical ladder” previously in place for
nurses, the organization’s “Nurse Pride” program encompasses
many initiatives in the hospital, including hand hygiene. Unit-
based nurses, who are trained to observe staff hand hygiene
performance, complete 100 observations over a 12-week
period to receive “pride points,” which are considered during
annual performance appraisals and merit increases. In 2007 a
nurse could earn up to an additional $8,000, depending on
the number of points accumulated.
“Caught You Caring” forms provide staff with a mecha-
nism to recognize other staff members in the act of providing
outstanding service. Hand hygiene is one component of this
incentive program, which recognizes staff members who go
above and beyond in providing excellent service to other staff
members or patients. The completed forms are given to an
employee’s manager, who considers the forms during the
annual review process.
The “Safety First” incentive program rewards staff for posi-
tive behavior in relation to various aspect of patient safety,
including hand hygiene. Employees receive scratch-off cards
and win instant prizes and become eligible for other prizes.
Brookhaven Memorial Hospital Medical Center is a 321-bed
acute care level II trauma center in Patchogue, New York. The
organization has monitored hand hygiene adherence since
2001 during infection control and environment of care
rounds, but the number of staff observed was originally small,
usually fewer than 50 per month.
In October 2003, following the hospitalwide placement of
alcohol-based hand rub dispensers, the infection control
department wanted to monitor staff use of the new product.
The infection control department developed a hand hygiene
data collection tool and began to ask employee volunteers to
anonymously observe fellow employees performing hand
hygiene; each was asked to complete 10 observations per
month.
The infection preventionist instructed the employees in
how to complete the form when they were given the data col-
lection tool. The observer noted the task being performed by
the employee at the time of the observation, whether hand
hygiene was performed, and the name of the employee.
The observed employee received a “congratulations” letter
or a “friendly reminder” letter. As an incentive for conducting
the observations and completing the data collection form, each
employee received two movie tickets when he or she submitted
the completed form to the infection control department.
Observations have increased from fewer than 50 per month to
about 100 per month. Hand hygiene adherence rates, which
have steadily improved since the employee observation process
began, are reported to administration, department heads, and
the infection control committee. Staff receive feedback from
department managers.
improvement.
61
Based on the experience of many in the
field, it often takes a long time to see the impact of
improved hand hygiene, particularly when the goal is to
incur long-term changes in behavior rather than short-term
responses to interventions that are frequently unsustained.
Some researchers have suggested that it may be unrealistic
to expect hospitals to sustain adherence rates of 90% to
100%, and they have questioned whether full adherence to
hand hygiene guidelines is a reasonable expectation.
62
For
example, Earl et al. found that even when alcohol-based
hand rub was provided in two intensive care units, hand
hygiene adherence rates improved but remained below
60%.
63
Nevertheless, with consistent monitoring, organiza-
tions should be able to demonstrate significant
improvements in hand hygiene adherence over time. By
using multiple measurement approaches, organizations can
also demonstrate increased structural capacity for hand
hygiene, as well as awareness of the importance of hand
hygiene and changes in attitudes among staff and patients.
14
The ultimate goal is to be able to demonstrate sustained
improvement over time.
KEY POINTS, CHAPTER 9
• The effectiveness of a quality improvement
effort in hand hygiene is affected by many
things, including leadership, intervention
approaches, organizational factors, personnel
and patient characteristics, and the external
environment.
• Top-down leadership support is critical to
success with improving hand hygiene
adherence.
• Improvement efforts should be tailored based
on targeted measurement and knowledge of
culture and setting; the same interventions
may not fit all areas.
• Several strategies have been shown to be
effective in enhancing hand hygiene practices,
including education, feedback, reminders, and
structured performance improvement
approaches.
118
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Text Box 9-5.
Educating Patients and Families
St. Joseph Medical Center in Bloomington, Illinois, part of
OSF Healthcare System, implemented GetWellNetwork, a
patient-centered technology that patients can access through
their television to view educational materials, hospital services,
and entertainment options. The educational offerings include a
segment on hand hygiene for patients.
Spartanburg Regional Healthcare System in Spartanburg,
South Carolina, posts small signs for patients and visitors that
say “Help us prevent the spread of germs. Before touching
clean supplies, food or drinks, please wash your hands or use
alcohol rub.”
In June 2008, the CDC launched the patient admission video
“Hand Hygiene Saves Lives,” which teaches patients and
visitors the importance of hand hygiene and encourages them
to remind health care workers to practice hand hygiene. The
video is available for download at no charge at
http://www.cdc.gov/handhygiene/Patient_
Admission_Video.html.
REFERENCES
1. Grol R., Grimshaw J.: From best evidence to best practice:
Effective implementation of change in patients’ care. Lancet
362:1225–1230, 2003.
2. Larson E.L., Quiros D., Lin S.X.: Dissemination of the CDC’s
hand hygiene guideline and impact on infection rates. Am J Infect
Control 35:666–675, Dec. 2007.
3. Boyce J.M., Pittet D.: Guideline for Hand Hygiene In Health-
Care Settings: Recommendations of the Healthcare Infection
Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect
Control Hosp Epidemiol 23(Suppl.):S3–S40, Dec. 2002.
4. Grol R., et al.: Planning and studying improvement in patient
care: The use of theoretical perspectives. Milbank Q 85(1):93-138,
2007.
5. Kretzer E.K., Larson E.L.: Behavioral interventions to improve
infection control practices. Am J Infect Control 26:245–253, 1998.
6. O’Boyle C.A., Henly S.J., Larson E.: Understanding adherence to
hand hygiene recommendations: The theory of planned behavior.
Am J Infect Control 29(6):352–360, 2001.
7. Whitby M., et al.: Behavioural considerations for hand hygiene
practices: The basic building blocks. J Hosp Infect 65:1–8, 2007.
8. Sax H., et al.: Determinants of good adherence to hand hygiene
among health care workers who have extensive exposure to hand
hygiene campaigns. Infect Control Host Epidemiol
28(11):1267–1274, 2007.
9. Ajzen I.: The theory of planned behavior. Organizational Behavior
and Human Decision Processes 50:179–211, 1991.
10. Whitby M., McLaws M.-L., Ross M.W.: Why healthcare workers
don’t wash their hands: A behavioral explanation. Infect Control
Hosp Epidemiol 27:484–492, May 2006.
11. Maskerine C., Loeb L.: Improving adherence to hand hygiene
among health care workers. J Contin Educ Health Prof
26:244–251, 2006.
12. Gould D.J., et al.: Interventions to improve hand hygiene
compliance in patient care. J Hosp Infect 68:193–202, 2008.
13. Backman C., Zoutman D.E., Marck P.B.: An integrative review of
the current evidence on the relationship between hand hygiene
interventions and the incidence of health care-associated
infections. Am J Infect Control 36:333–348, 2008.
14. Ontario, Canada, Ministry of Health and Long-Term Care: A
Quick Guide to Just Clean Your Hands: A Provincial Hand Hygiene
Improvement Program for Hospitals. 2008.
http://www.justcleanyourhands.ca/pdf/14_5_A_Quick_Guide.pdf
(accessed Dec. 6, 2008).
15. Pittet D.: Improving compliance with hand hygiene in hospitals.
Infect Control Hosp Epidemiol 21:381–386, 2000.
16. Pittet D., Boyce J.M.: Hand hygiene and patient care: Pursuing
the Semmelweis legacy. Lancet:9–20, Apr. 2001.
www.kliinikum.ee/ikt/doc/oppematerjalid/Referaadid/HospitadlH
ospitaa/in.pdf.
17. Fung C.H., et al.: Systematic review: The evidence that publishing
patient care performance data improves quality of care. Ann Intern
Med 148:111–123, 2008.
18. Jamtvedt G., et al.: Does telling people what they have been doing
change what they do? A systematic review of the effects of audit
and feedback. Qual Saf Health Care 15:433–436, 2006.
19. World Health Organization (WHO), World Alliance for Patient
Safety: Global Patient Safety Challenge 2005–2006: Clean Care Is
Safer Care. Geneva: WHO, 2006. http://www.who.int/gpsc/en/
(accessed Dec. 5, 2008).
20. Sax H., et al.: “My five moments for hand hygiene”: A user-
centred design approach to understand, train, monitor and report
hand hygiene. J Hosp Infect 67:9–21, 2007.
21. Bittner M.J., et al.: Limited impact of sustained simple feedback
based on soap and paper towel consumption on the frequency of
hand washing in an adult intensive care unit. Infect Control Hosp
Epidemiol 23:120–126, 2002.
22. Pittet D., et al.: Effectiveness of a hospital-wide programme to
improve compliance with hand hygiene. Lancet 356:1307–1312,
Oct. 14, 2000. Errata in: Lancet 356:2196, Dec. 13–20, 2000.
23. Ontario, Canada, Ministry of Health and Long-Term Care: Just
Clean Your Hands: Reminders in the Workplace.
http://www.justcleanyourhands.ca/reminders_in_the_workplace.p
hp (accessed Dec. 5, 2008).
24. Institute for Healthcare Improvement (IHI): How-to Guide:
Improving Hand Hygiene. Cambridge, MA: IHI, Apr. 3, 2006.
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Tools/
HowtoGuideImprovingHandHygiene.htm (accessed Dec. 6,
2008).
25. Pande P.S., Neuman R.P., Cavanagh R.R.: The Six Sigma Way:
How GE, Motorola and Other Top Companies Are Honing Their
Performance. New York: McGraw-Hill, 2000.
26. Lazarus I.R., Butler K.: The promise of Six Sigma, Part I.
Managed Healthcare Executive 11:22–26, Oct. 2001.
28. Nelson E.C., Batalden P.B., Godfrey M.M.: Quality by Design: A
Clinical Microsystems Approach. San Francisco: Jossey-Bass; 2007.
27. Lazarus I.R., Stamps B.: The promise of Six Sigma, Part 2.
Managed Healthcare Executive 12:27–30, Jan. 2002.
29. Eldridge N.E., et al.: Using the Six Sigma process to implement
the Centers for Disease Control and Prevention Guideline for
Hand Hygiene in 4 intensive care units. J Gen Intern Med
21:S35–S42, 2006.
30. Cochrane Effective Practice and Organisation of Care Review
Group: Data Collection Checklist.
http://www.epoc.cochrane.org/Files/Website%20files/Documents/
Reviewer%20Resources/datacollectionchecklist.pdf (accessed Nov.
3, 2008).
31. Ranji S.R., et al.: Prevention of Healthcare-Associated Infections.
Rockville, MD: Agency for Healthcare Research and Quality, Jan.
2007.
32. Positive Deviance Initiative Web site,
http://www.positivedeviance.org/ (accessed Nov. 3, 2008).
119
Measurement Is Only the Beginning: Factors That Contribute to Improvement
33. Gawande A.: Better. A Surgeon’s Notes of Performance. New York:
Metropolitan Books, Henry Holt and Company, 2007.
34. Lam B.C.C., Lee J., Lau Y.L.: Hand hygiene practices in a
neonatal intensive care unit: A multimodal intervention and
impact on nosocomial infection. Pediatrics 114:e565–e571, 2004.
35. Larson E.L.: State-of-the-science—2004: Time for a “no
excuses/no tolerance” (NET) strategy. Am J Infect Control
33(9):548–557, 2005.
36. Rosenthal V.D., et al.: Effect of education and performance
feedback on handwashing: The benefit of administrative support
in Argentinean hospitals. Am J Infect Control 31:85–92, 2003.
37. Lankford M.G., et al.: Influence of role models and hospital
design on hand hygiene of healthcare workers. Emerg Infect Dis
Feb. 9, 2003. http://www.cdc.gov/ncidod/EID/vol9no2/02-
0249.htm (accessed Dec. 6, 2008).
38. Snow M., et al.: Mentors’ hand hygiene practices influence
students’ hand hygiene rates. Am J Infect Control 34:18–24, 2006.
39. Hand washing: A modest measure—With big effects. BMJ
311:686, 1999.
40. Pittet D., et al.: Hand hygiene among physicians: Performance,
beliefs, and perceptions. Ann Intern Med 141:1–8, 2004.
41. The Joint Commission: Hand Hygiene: Toolkit for Implementing
the National Patient Safety Goal. Oakbrook Terrace, IL: Joint
Commission Resources, 2008.
42. MacDavitt K., Chou S.-S., Stone P.W.: Organizational climate and
health care outcomes. Jt Comm J Qual Patient Saf
33(Suppl.):45–56, Nov. 2007.
43. Frankel, A.S. (ed.): Strategies for Building a Hospitalwide Culture of
Safety. Oakbrook Terrace, IL: Joint Commission Resources, 2006.
44. Flin R., et al.: Measuring safety climate in health care. Qual Saf
Health Care 15:109–115, 2006.
45. Roberts K.H.: Managing high reliability organizations. California
Management Review 32:101–113, 1990.
46. Weick K.E.: Organizational culture as a source of high reliability.
California Management Review29:112–127, 1987.
47. Pizzi L., Goldfarb N., Nash D.: Promoting a culture of safety. In
Shojania K.G., et al. (eds.): Making Health Care Safer: A Critical
Analysis of Patient Safety Practices. Rockville, MD: Agency for
Healthcare Research and Quality, 2001.
48. Sinkowitz-Cochran R.L., et al.: An Evaluation of Organizational
Culture and Perceptions of Hand Hygiene Following a Multi-center
Randomized Trial to Reduce the Transmission of Antimicrobial-
Resistant Bacteria. Society for Healthcare Epidemiology of America
annual meeting, Orlando, FL, April, 2008.
49. Larson E.L., et al.: An organizational climate intervention
associated with increased handwashing and decreased nosocomial
infections. Behav Med 26:14–23, Spring 2000.
50. McGuckin M., et al.: The effect of random voice hand hygiene
messages delivered by medical, nursing, and infection control staff
on hand hygiene compliance in intensive care. Am J Infect Control
34(10):673–675, 2006.
51. McGuckin M., et al.: Evaluation of a patient education model for
increasing hand hygiene compliance in an inpatient rehabilitation
unit. Am J Infect Control 32:325–328, 2004.
52. McGuckin M., et al.: Evaluation of a patient-empowering hand
hygiene programme in the UK. J Hosp Infect 48:222–227, 2001.
53. McGuckin M., et al.: Patient education model for increasing
handwashing compliance. Am J Infect Control 27:309–314, 1999.
54. McGuckin M., et al.: Global Perspectives on Patient Empowerment
and Hand Hygiene Compliance: A Realistic Goal for a Multifaceted
WHO Strategy. Society for Healthcare Epidemiology of America
scientific meeting, Orlando, FL, April, 2008.
55. National Patient Safety Agency (NPSA): cleanyourhands Campaign.
http://www.npsa.nhs.uk/cleanyourhands/ (accessed Aug. 15,
2008).
56. Gould D.J., et al.: The cleanyourhands campaign: Critiquing
policy and evidence base. J Hosp Infect 65:95–101, 2007.
57. Entwistle V.A., Mello M., Brennan T.A.: Advising patients about
patient safety: current initiatives risk shifting responsibility. Jt
Comm J Qual Patient Saf 31:483–494, Sep. 2005.
58. Pittet D., Perneger T.: Compliance with handwashing. Ann Intern
Med 1331(4):310, Aug. 1999.
59. Association for Professionals in Infection Control and
Epidemiology: Legislation in Progress.
http://www.apic.org/scriptcontent/custom/dyncontent/legislation/i
ndex.cfm?section=government_advocacy (accessed Dec. 6, 2008).
60. Centers for Medicare & Medicaid Services: Hospital-Acquired
Conditions (Present on Admission Indicator): Overview.
http://www.cms.hhs.gov/HospitalAcqCond/01_Overview.asp
(accessed Dec. 6, 2008).
61. Clare Barry, B.N., M.S.C., C.I.C., Ministry of Health and Long-
term Care Ontario, Canada, personal communication, Dec. 2007.
62. Pittet D., Mourouga P., Perneger T.V.: Compliance with
handwashing in a teaching hospital infection control program.
Ann Intern Med 130:126–130, Jan. 1999.
63. Earl M.L., Jackson M.M., Rickman L.S.: Improved rates of
compliance with hand antisepsis guidelines: A three-phase
observational study. AJN 101(3):26–33, 2001.
120
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
RESOURCES FROM ORGANIZATIONS
COLLABORATING IN MONOGRAPH
DEVELOPMENT
Six leading organizations in the area of infection control
and infectious diseases collaborated on this monograph to
identify promising approaches to monitoring hand hygiene
performance in health care organizations. A brief overview
of these collaborating organizations and their available
resources for measuring and improving hand hygiene are
presented here:
Association for Professionals in Infection
Control and Epidemiology, Inc.
The mission of the Association for Professionals in
Infection Control and Epidemiology, Inc. (APIC) is to
improve health and patient safety by reducing risks of
infection and other adverse outcomes. APIC, a nonprofit,
international organization founded in 1972, is located in
Washington, DC, and provides its nearly 12,000 members
with resources such as educational tools and annual
educational conferences, practice guidance, and extensive
resource materials available on its Web site
(http://www.apic.org). APIC advances its mission through
research, collaboration, public policy, practice guidance,
and credentialing. APIC seeks to influence and improve the
practice and management of infection prevention and
control and recognizes the central role hand hygiene plays
in infection prevention. APIC debuted the patient safety
DVD “Hand Hygiene Saves Lives” at its annual conference
in Denver, Colorado, June 15 through 19, 2008. APIC was
also a member of the hand hygiene task force that
developed the Centers for Disease Control and Prevention’s
(CDC’s) 2002 “Guideline for Hand Hygiene in Health-
Care Settings” and the Institute for Healthcare
Improvement (IHI) panel that developed the How-to
Guide: Improving Hand Hygiene.
Centers for Disease Control and Prevention
The CDC, located in Atlanta, Georgia, and one of the major
operating components of the U.S. Department of Health
and Human Services, seeks to promote health and quality of
life by preventing and controlling disease, injury, and
disability by working with partners throughout the nation
and the world. A recognized leader in the development of
health care guidance documents, the CDC’s Healthcare
Infection Control Practices Advisory Committee (HICPAC)
developed hand hygiene guidelines in 2002, in collaboration
with the Society for Healthcare Epidemiology of America
(SHEA), APIC, and the Infectious Diseases Society of
America (IDSA). The CDC promotes hand hygiene through
its extensive references and resources available on its Web site
(http://www.cdc.gov), and it recently partnered with APIC
and the Safe Care Campaign to make the patient safety
DVD “Hand Hygiene Saves Lives.”
Institute for Heathcare Improvement
The IHI, an independent not-for-profit organization
founded in 1991 and located in Cambridge, Massachusetts,
strives to accelerate improvement in health and health care
worldwide by helping individuals develop skills to lead
121
chapter 10
RESOURCES FOR MEASUREMENT
AND IMPROVEMENT
improvement initiatives and facilitate organizational
change. The IHI supports extensive resources, many of
which are available at its Web site (http://www.ihi.org),
including educational conferences and seminars on
improvement initiatives and techniques, documents and
tools for improvement, and networking for its members. To
help organizations reduce health care–associated infections
by improving hand hygiene, the IHI recently developed the
How-to Guide: Improving Hand Hygiene, in collaboration
with the CDC, APIC, and SHEA.
National Foundation for Infectious Diseases
The National Foundation for Infectious Diseases (NFID), a
nonprofit organization founded in 1973 and located in
Bethesda, Maryland, is dedicated to educating health care
professionals and the public about the causes, treatment,
and prevention of infectious diseases. The NFID holds
conferences and meetings on various infectious disease
topics and provides publications, fact sheets, and a virtual
library on infectious diseases to health professionals and the
public on its Web site (http://www.nfid.org). Recognizing
the important role that hand hygiene plays in the
transmission of infectious diseases and conditions, the
NFID has incorporated information about hand hygiene
into many of its fact sheets and educational materials.
Society for Healthcare Epidemiology of
America
SHEA, located in Rosslyn, Virginia, was organized in 1980
to foster the development and application of the science of
health care epidemiology. SHEA’s mission to prevent and
control infections in health care organizations is evident in
its educational offerings, online resource materials, and
development of practice guidelines (see http://www.shea-
online.org). SHEA was a member of the hand hygiene task
force that developed the 2002 “Guideline for Hand
Hygiene in Health-Care Settings” and the IHI panel that
developed the IHI How-to Guide: Improving Hand Hygiene.
World Health Organization
The World Health Organization (WHO) in Geneva,
Switzerland, is the coordinating and directing authority for
health within the United Nations systems. Founded in
1948, the WHO’s responsibilities include providing
leadership on global health matters, setting norms and
standards, monitoring and assessing health trends, and
providing evidence-based recommendations and technical
support to countries. In 2004 the WHO initiated the
World Alliance for Patient Safety (WAPS), which raises
awareness to improve safe care and facilitates the
development of patient safety policy and practices in all
WHO member states. The first Global Patient Safety
Challenge, “Clean Care Is Safer Care,” was launched in
October 2005, with its initial focus on hand hygiene.
Expanding on the Swiss national hand hygiene campaign
educational and promotional tools, the WHO developed
draft guidelines for hand hygiene that have been extensively
field tested. The guidelines were finalized in 2008 and are
being officially reissued during the first quarter of 2009.
Examples of resources from the collaborating organizations
in the Consensus Measurement in Hand Hygiene
(CMHH) are listed in Table 10-1.
JOINT COMMISSION INITIATIVES
The Joint Commission, the WHO Collaborating Centre
for Patient Safety Solutions, and Joint Commission
Resources (JCR) all have useful resources related to improv-
ing hand hygiene adherence, some of which are listed in
Table 10-2.
INTERNATIONAL RESOURCES
Globally there is much interest in improving hand hygiene
adherence. There are several initiatives in place that have
field-tested publicly available data collection tools, training
programs, and implementation strategies. Some of these
international initiatives are highlighted in Table 10-3.
ADDITIONAL RESOURCES
Table 10-4 provides additional resources from organizations
that have Web sites that provide hand hygiene resources.
122
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
123
Resources for Measurement and Improvement
Table 10-1.
Resources from the Consensus Measurement in Hand Hygiene (CMHH) Project
Collaborators
Web Site
http://www.apic.org/Content/NavigationMenu/
Education/EducationResources/
EducationalBrochures/Educational_Brochur.htm
http://www.knowledgeisinfectious.org
http://www.cdc.gov/handhygiene
http://www.cdc.gov/cleanhands/
http://www.ihi.org/IHI/Topics/CriticalCare/
IntensiveCare/Tools/HowtoGuideImproving
HandHygiene.htm
http://www.nfid.org/factsheets
http://www.nfid.org/docs/workplaceflu.html
Description
This site links the reader to several general educational brochures for both the
general public and health care workers on various infection control and
infectious disease-related topics, including hand hygiene.
This site is dedicated to the provision and exchange of information on the
control and eradication of health care–associated infections (HAIs). It is
designed to promote open dialogue among infection prevention and control
professionals, hospital administration executives, physicians, and other health
care professionals. Includes links to other Web sites, guidelines, news,
research, and upcoming events related to the prevention and control of HAIs.
The CDC’s hand hygiene site contains links to the following, as well as other
educational resources on hand hygiene:
• The CDC’s 2002 Guideline for Hand Hygiene in Healthcare Settings
• The “Hand Hygiene Interactive Training Course,” which reviews key
concepts of hand hygiene and other standard precautions to prevent
health care–associated infections. It also contains a link to printable
versions of five different full-size hand hygiene promotional posters. The
patient admission video “Hand Hygiene Saves Lives,” which teaches
patients and visitors the importance of hand hygiene and encourages
them to remind health care workers to practice hand hygiene. This video
was a collaborative project between CDC, APIC, and the Safe Care
Campaign.
This site contains information for the general public on hand hygiene.
The IHI’s How-to Guide: Improving Hand Hygiene was developed in
collaboration with CDC, APIC, and SHEA, with input from the WHO’s
World Alliance for Patient Safety
This site makes available informational fact sheets, such as “Community-
Associated Methicillin-Resistant Staphylococcus aureus Infections,” which
discuss aspects of prevention, such as using good hand hygiene.
NFID has developed an educational bulletin titled “Help Reduce the
FLU@Work” that can be posted in the workplace to help companies
minimize the spread of flu. The bulletin highlights the importance of hand
hygiene in flu prevention.
Association for Professional in Infection Control and Epidemiology, Inc. (APIC)
Centers for Disease Control and Prevention (CDC)
Institute for Healthcare Improvement (IHI)
National Foundation for Infectious Diseases (NFID)
124
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Table 10-1. (continued)
http://www.shea-online.org/
hand_hygiene-page.cfm
http://www.shea-online.org/
search_results.cfv?srchterm=hand+hygiene
http://www.who.int/gpsc/en/
http://www.journals.uchicago.edu/toc/iche/
2008/29/s1
This is SHEA’s hand hygiene site, which provides links to relevant resources
regarding hand hygiene. The site contains links to the 2002 CDC guideline
on hand hygiene, as well as news, published research, and SHEA abstracts
related to hand hygiene.
This site provides links to numerous topics and studies related to hand
hygiene.
This is the home page for the WHO’s “Clean Care Is Safer Care” initiative,
the WHO’s first Global Patient Safety Challenge. It provides links to
multiple aspects of the challenge, including the following:
• A description of the pilot testing of the WHO’s hand hygiene guideline
• Hand hygiene tools, resources, and information, including the following:
— The “Five Moments for Hand Hygiene” poster and associated tools
— The WHO Guideline on Hand Hygiene in Health Care (Advanced
Draft): A Summary
• Articles related to the challenge
The “Compendium of Strategies to Prevent Healthcare-Associated Infections
in Acute Care Hospitals” describes indications for hand hygiene in relation to
recommended practices for preventing the following infections: central
line–associated blood stream infections, ventilator-associated pneumonia,
catheter-associated urinary tract infections, surgical site infections,
transmission of methicillin-resistant Staphylococcus aureus (MRSA), and
Clostridium difficile infections. The information was published in Volume 29
of Infection Control and Hospital Epidemiology in 2008.
Society for Healthcare Epidemiology of America (SHEA)
World Health Organization (WHO) World Alliance for Patient Safety (WAPS)
Multiple Partners
Web Site Description
125
Resources for Measurement and Improvement
Table 10-2.
Resources from The Joint Commission, the WHO Collaborating Centre for Patient
Safety, and Joint Commission Resources
Web Site
http://www.jointcommission.org/PatientSafety/
SpeakUp/
http://www.ccforpatientsafety.org
http://www.jcrinc.com
Description
The Joint Commission’s Speak Up! campaign includes two printer-friendly
brochures and posters that discuss the importance of hand hygiene:
• “Five Things You Can Do to Prevent Infections”
• “Help Prevent Errors in Your Care”
This is the home page for the WHO Collaborating Centre for Patient Safety
Solutions, devoted to improving the overall quality of care and advancing
patient safety. The basic purpose of the solutions is to guide the redesign of
care processes to prevent inevitable human errors from actually reaching
patients. From this page there are links to the following:
• “Patient Safety Solutions,” including “Solution Nine,” which describes
the issues surrounding hand hygiene in health care organizations and
provides suggested actions for promoting hand hygiene adherence as well
as references and other resources
• Information about the “High 5s Project,” a collaboration between the
Commonwealth Fund, the WHO World Alliance for Patient Safety, and
the WHO Collaborating Center for Patient Safety. This initiative is a
mechanism to implement innovative standardized operating protocols for
five patient safety solutions over five years, with promotion of effective
hand hygiene practices one of the chosen solution areas.
From JCR’s home page, you can access a number of resources related to hand
hygiene by searching on “hand hygiene” in the “Products and Services”
section. Available products include “Ask Me if I Washed My Hands” and
“Stopping Infection Is in Our Hands” buttons for health care workers to
wear; posters to communicate the importance of adhering to recommended
hand hygiene practices; and a multimedia toolkit designed to help
organizations implement National Patient Safety Goal 7. In 2008, JCR
published a toolkit called, “Hand Hygiene: Toolkit for Implementing the
National Patient Safety Goal” to help organizations comply with Joint
Commision accreditation requirements.
The Joint Commission
The WHO Collaborating Centre for Patient Safety Solutions
Joint Commission Resources (JCR)
126
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Table 10-3.
International Resources
Web Site
See Table 10-1.
http://www.npsa.nhs.uk/cleanyourhands
http://www.idrn.org/nosec.php
http://www.justcleanyourhands.ca
Description
This is the home page for the campaign launched by the England and Wales
NPSA in April 2005. All pages have links to the training video; the links at
the top of this page will take you to the following:
• The Campaign: Includes the latest news and approaches used and
describes the components of the campaign.
• Achievements: Includes independent evaluation of the effectiveness of the
campaign.
• The Campaign in Hospitals: Describes the campaign’s implementation in
hospitals and provides a link to the Hand Hygiene Observation Tool
(HHOT), including instructions for its use.
The remaining links at the top of the home page include links for the
campaign in the community, FAQs, useful links, and campaign contact
information.
This is the direct link to the National Observational Study to Evaluate the
cleanyourhands Campaign (NOSEC), as well as the full version and short
summary of the standard operating procedures for the HHOT.
This is the home page for Ontario’s hand hygiene program. From this page,
there are links to extensive resources, such as the following:
• An overview of the program, which includes A Quick Guide to Just
Clean Your Hands
• Environmental aspects of the program, including placement of hand
hygiene products and the skin care program
• Training and education resources, such as PowerPoint presentations and a
Q&A document
• The observation tool and evaluation materials
• The “Observation Analysis Tool,” an Excel workbook to assist in
analyzing data collected using the observation tool
• The “On the Spot” feedback tool
• Role descriptions for “champion” and “observer”
• Reminders, such as posters and pocket cards
• A step-by-step guide for local implementation of the program
WHO-WAPS “Clean Care Is Safer Care”
England and Wales National Patient Safety Agency (NPSA) “cleanyourhands” Campaign
Ontario, Canada “Just Clean Your Hands” Program
127
Resources for Measurement and Improvement
Table 10-3. (continued)
http://www.cec.health.nsw.gov.au/moreinfo/
cleanhandsintro.html
http://www.washyourhandsofthem.com/
http://www.hps.scot.nhs.uk/haiic/ic/
handhygiene.aspx
http://www.hopisafe.ch
http://www.swisshandhygiene.ch
http://handhygiene.ca
From the NSW campaign home page there are links to many resources,
including the following:
• An overview of campaign posters and educational materials for health
care workers, patients, and visitors
• An Implementation Guide, as well as a hand hygiene assessment tool and
several fact sheets
The campaign, launched by Health Protection Scotland (HPS), has links
from its home page to various resources, including the following:
• An overview of the campaign
• Campaign materials, such as posters, leaflets, and other hand hygiene
documents
This is the Web site for HPS’s “HAI & Infection Control Resource Centre
for the Hand Hygiene” model infection control policy. It includes a range of
practical resources that can be used to support local activities regarding hand
hygiene.
This Web site was created by the University of Geneva Hospitals [Hopitaux
Universities de Geneve (HUG)] to share its experience in implementing a
hospitalwide, multimodal hand hygiene program. This Web site offers the
following:
• The action agenda, which describes HUG’s initiative
• Geneva posters (“Talking Walls”)
• Results of the initiative
• References and links regarding hand hygiene
This Web site contains information on the swisshandhygiene campaign (in
French).
This is the home page for the pan-Canadian hand hygiene campaign,
launched in October 2007, intended to support, supplement, and integrate
existing hand hygiene initiatives locally, regionally, and provincially. The site
contains links to hand hygiene resources and references, FAQs, and
information for Canadian organizations that are interested in joining the
campaign.
Web Site Description
New South Wales, Australia’s “The Clean Hands Saves Lives” Campaign
University of Geneva Hospitals, Geneva, Switzerland
Scotland, United Kingdom “Germs, Wash Your Hands of Them” Campaign
Swiss “swisshandhygiene” Campaign
Canadian Patient Safety Institute (CPSI) “STOP! Clean Your Hands” Campaign
128
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Table 10-4.
Additional Resources
Web Site
http://www.va.gov/ncps/SafetyTopics/
HandHygiene/index.html
http://www.publichealth.va.gov/
InfectionDontPassItOn/
http://www.handhygiene.org
http://www.safecarecampaign.org
Description
This site includes hand hygiene tools and information, including the
following:
• A hand hygiene/glove use observation tool for recording hand hygiene
practices and instructions for using the tool
• A health care worker questionnaire for measuring perceptions and
attitudes regarding hand hygiene
• An Excel spreadsheet for computing grams of alcohol product used per
patient day
• A checklist of interventions developed in the VA-3M Six Sigma Project to
improve Hand Hygiene Practices
• Sample data from four VA medical center intensive care units
• Links to hand hygiene references and Web sites
“Infection: Don’t Pass It On” campaign is a VA public health campaign. The
goal of the campaign is to involve staff, patients, and visitors in taking basic
steps to preventing infection. The focus of the campaign is hand hygiene and
cough etiquette, and the site includes posters that are printer-ready.
The Hand Hygiene Resource Center was developed by St. Raphael
Healthcare System and Dr. John Boyce. The site includes many resources,
including the following:
• PowerPoint slide presentations on improving hand hygiene in health care
facilities
• A guidance document on selecting the right hand rub
• St. Raphael’s hand hygiene monitoring tool
The Safe Care Campaign Web site was developed by Victoria and Armando
Nahum after three health care–associated infections, culminating in the death
of their son in 2006. The campaign’s focus is on stopping health
care–associated and community infections. This Web site contains many
resources, including information on hand hygiene for both health care
workers and patients/families and “A Patient’s Guide to Safe Care.”
Department of Veterans Affairs
Hand Hygiene Resource Center—Project of St. Raphael Healthcare System
Safe Care Campaign
This Appendix provides examples of some of the tools that are described in the monograph. The examples are provided to
illustrate concepts in the text and are not intended to be complete, comprehensive or used without additional information.
We strongly encourage readers to go directly to the tool developers and sources described in Chapter 10 of the mono-
graph to get the most recent versions of tools and instructions. Tools are modified frequently and space constraints generally
prohibit including essential components such as instructions for use, training materials and analysis recommendations.
129
appendix
EXAMPLES OF MEASUREMENT TOOLS
LIST OF TOOLS
130
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
LIST OF TOOLS (CONT’D)
131
Appendix: Examples of Measurement Tools
132
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
133
Appendix: Examples of Measurement Tools
134
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
135
Appendix: Examples of Measurement Tools
136
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
137
Appendix: Examples of Measurement Tools
138
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
139
Appendix: Examples of Measurement Tools
140
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
141
Appendix: Examples of Measurement Tools
142
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
143
Appendix: Examples of Measurement Tools
144
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
145
Appendix: Examples of Measurement Tools
146
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
147
Appendix: Examples of Measurement Tools
148
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
149
Appendix: Examples of Measurement Tools
150
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
151
Appendix: Examples of Measurement Tools
152
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
153
Appendix: Examples of Measurement Tools
154
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
155
Appendix: Examples of Measurement Tools
156
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
157
Appendix: Examples of Measurement Tools
158
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
159
Appendix: Examples of Measurement Tools
160
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
161
Appendix: Examples of Measurement Tools
162
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
163
Appendix: Examples of Measurement Tools
164
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
165
Appendix: Examples of Measurement Tools
166
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
167
Appendix: Examples of Measurement Tools
168
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
169
Appendix: Examples of Measurement Tools
170
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
171
Appendix: Examples of Measurement Tools
172
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
173
Appendix: Examples of Measurement Tools
174
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
175
Appendix: Examples of Measurement Tools
176
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
177
Appendix: Examples of Measurement Tools
178
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
179
Appendix: Examples of Measurement Tools
180
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
181
Appendix: Examples of Measurement Tools
182
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
183
Appendix: Examples of Measurement Tools
184
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
185
Appendix: Examples of Measurement Tools
186
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
187
Appendix: Examples of Measurement Tools
188
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
189
Appendix: Examples of Measurement Tools
190
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
191
Appendix: Examples of Measurement Tools
192
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
A
Academic detailing, 111
Accrediting bodies, 116
Actions, hand hygiene, 2
components of, measurement of, 13–14, 17, 19
relationship to indications or opportunities, 20
Adherence rates
accuracy of, 102
direct observation method, 29–32
all-or-none measures and calculations, 31–32
composite measures and calculations, 31, 32
item-by-item measures and calculations, 30, 32
by health care worker discipline, 21–22, 40–42, 65–66
infection rates, relationship to, 96, 100–102, 103–105
issues that influence, 20, 34–40
measurement of, xvi
opportunities measured and, 20, 34–35
patient mix and intensity of patient care and, 20,
36–40, 55
product use method, 58–59
stratified rates, 95, 97–99
Adherence to hand hygiene guidelines. See also
Improvement interventions and initiatives; Measurement
of adherence
audit and feedback of adherence data, 110
competence reviews for staff and, 21
definitions, xxvii
determination of, xv
failure to adhere, xxii, 21
accountability of staff, 114, 115
factors that influence, 2, 3
product use method and, 54
worker characteristics and, xv–xvi
hand hygiene and reduction of infections, xvi, 1
importance of, 1
National Patient Safety Goal 7, xvii, 2
organizational factors, xx, 109, 111–114, 115
statistics on, reliability of, xvi
Administrative leaders, 113
Alcohol-based hand rubs. See also Product use method
education on use of, 73–75
spreadsheets from Veterans Administration National
Center for Patient Safety, 58, 128
staff education on, 53
survey on staff satisfaction, 130, 182–186
techniques for using, 73, 74
All-or-none measures and calculations, 31–32
Amager Hospital hand hygiene technique assessment, 75,
77
APIC (Association for Professionals in Infection Control
and Epidemiology, Inc.), xx, xxi, 121, 123
Artificial nails and fingernails, xix, 14, 17, 78–79
Asante Health System, staff as observers, 26
Association for Professionals in Infection Control and
Epidemiology, Inc. (APIC), xx, xxi, 121, 123
Attitudes Regarding Practice Guidelines, 130, 165–166
Audit and feedback, 110
Auditory reminders, 110
193
INDEX
194
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Australia, Department of Health and Aging, 1. See also
New South Wales Department of Health “Clean Hands
Save Lives” campaign
B
Baseline Questionnaire of the Perception of Hand Hygiene
and Health Care-associated Infections for Health-care
Workers (WHO), 130, 157–160
Basic Hand Hygiene Observation Tool (WHO), 129,
135–136
Behavioral theoretical model, 108
Bellin Health System statistical process control charts, 100
Bias, xxvii, 28–29
Bloodstream infections, 102
Brookhaven Memorial Hospital Medical Center
fingernails and artificial nails policy, 79
patient satisfaction surveys, 67
product use method, 56
staff incentives and rewards program, 117
C
Canadian Patient Safety Institute “STOP! Clean Your
Hands” campaign, 89, 127
Canadian rehabilitation hospital, electronic monitoring
systems for product use measurement, 57
Caritas Norwood Hospital, product measurement system
with benchmarking, 60
“Caught You Caring” form, 117
Centers for Disease Control and Prevention (CDC), 121,
123
CMHH project, xxi
hand hygiene and reduction of infections, xvi
hand hygiene guidelines, xvii, 1
adherence rates and infection rates, relationship
between, 100
fingernails and artificial nails, 78
glove use, 1, 80–81
hand rubbing, 21
multidisciplinary programs, 110
rings and jewelry, 80
techniques for hand hygiene, 73
updates to, xxii
WHO guidelines compared to, 6–11
“Hand Hygiene Saves Lives” video (CDC), 118, 121
Healthcare Infection Control Practices Advisory
Committee (HICPAC), 121
Web site, xx
Central line infections bundle (IHI), 102
China hand hygiene surveillance project, 92
“Clean Care is Safer Care” initiative (WHO), xix, xxii, 81,
87–88, 122, 124
“Clean Hands Save Lives” campaign, xx, 90–91, 127
data collection tool, 90
Cleansing, thoroughness of. See Thoroughness of cleansing
“cleanyourhands” campaign (NPSA), xix–xx, 88, 126
Hand Hygiene Observation Tool (HHOT), xx, 23,
88–89, 129, 139–142
“It’s OK to Ask” study, 116
National Observation Study to Evaluate the “cleany-
ourhands” Campaign (NOSEC), xix–xx, 88–89
patient involvement in, 116
Cleveland Clinic “Managing Toward Daily Compliance”
initiative, 112
Clinical Excellence Commission, 90
Clinical leaders, 113–114
CMHH. See Consensus Measurement in Hand Hygiene
(CMHH) project
Cognitive theoretical model, 108
Collaborating Centre for Patient Safety Solutions (WHO),
125
“Compendium of Strategies to Prevent Healthcare-
Associated Infections in Acute Care Hospitals,” 124
Composite measures and calculations, 31, 32
Consensus Measurement in Hand Hygiene (CMHH)
project, xvii, xxi–xxii, 29, 66, 78–79
Consumer groups, 116
Control charts, xx, 95, 100
Convenience sampling, 49
Covert versus overt observation, 26–28, 50–51
Culture of safety, 114
D
Dana Farber Cancer Institute, electronic counting device
for product use measurement, 56–57
Dartmouth-Hitchcock Medical Center, electronic moni-
toring systems for product use measurement, 57
195
Index
Dashboard, xx, 95, 96
Data
accuracy of, xxiii
analysis of, xx
benchmarking through product measurement system,
60
spreadsheets from Veterans Administration National
Center for Patient Safety, 58, 128
collection of
direct observation method, xvi, xviii, 20–29, 34–49
direct observation method, patient use for, 25–26, 27
direct observation method, staff use for, 25, 26
documentation of methodology, 29
by health care worker discipline, 21–22, 40–42
Observation Audit Tool, 75, 76–77
product use method, xix, 54–55
standardized tools, xxiii
surveys, xix
tools for, 90, 91–92
tools for, limitations of, xxiii
training on, xxii
display and reporting of, xx
adherence rates and infection rates, relationship
between, 101
control charts, xx, 95, 100
dashboard, xx, 95, 96
unit- and discipline-level reporting, 95, 97–99
Denver Health and Hospital Authority staff incentives and
rewards program, 117
Direct observation method
actions, measurement of, 13–14, 17, 19
adherence rates, calculating, 29–32
all-or-none measures and calculations, 31–32
composite measures and calculations, 31, 32
item-by-item measures and calculations, 30, 32
advantages and limitations of, xvi, xviii, 18, 19
CMHH project, xxii
conducting observations, 22–29
double counting, 22, 23
frequency of observations, 22–23
Hawthorne effect, 27–28, 29, 50–51, 90
number of observations needed, 23
overt versus covert observation, 26–28, 50–51
privacy considerations, 28
sampling strategies, 24–25, 49
scheduling observations, 24
structured approach to, 24, 43–48
technology use, 28–29
who will conduct observations, 25–26
data collection, xvi, xviii
documentation of methodology, 29
description of, 14, 18, 19
elements to measure, 13–14, 17, 19
what to observe, 20–21
who to observe, 21–22, 40–42
opportunities, measurement of, 19, 20, 34–35
product use method and, 15, 53–54, 61–62
reliability among observers, 29, 30
standardization of observation, 20, 29
structural considerations and, 14, 19
success of, xviii
tools for
Basic Hand Hygiene Observation Tool, 129,
135–136
China hand hygiene surveillance project, 92
Hand Hygiene Observation Tool (HHOT), xx, 23,
88–89, 129, 139–142
Health Protection Scotland audit tool, 91–92
instructions on observation forms, 29
Mayo Clinic Hand Hygiene and Glove Use
Monitoring Form, 32, 129, 145–146
Observation Tool and Calculation Form, 129,
131–134
Ontario Observation Tool, 89–90, 129, 137–138
Overt Observational Instructions and Tool, 129,
147–151
Reedsburg Area Medical Center Observation Tool,
129, 143–144
Double counting, 22, 23
E
Eastern Maine Medical Center
multiple methods to measure hand hygiene, 16
patient satisfaction surveys, 67
product measurement system with benchmarking, 60
196
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Education and training of staff
academic detailing, 111
on alcohol-based hand rubs, 53
for data collection, xxii
educational outreach visits, 111
on hand hygiene, 2, 73, 110
on hand hygiene techniques, 73–75
observer training, 25, 29
surveys to help plan and guide, 64
Education of patients, 118
Elective behavior, 108
Electronic counting device for product use measurement,
55–57
Electronic monitoring systems for product use measure-
ment, 57–58
England and Wales
initiatives in (see “cleanyourhands” campaign (NPSA))
National Health Service, 1
Evaluation of tolerability and acceptability of alcohol-
based hand rub (WHO), 130, 182–186
Evidence-based guidelines, xxi
External environment, 109, 116
F
Failure to perform hand hygiene, xxii, 21
accountability of staff, 114, 115
factors that influence, 2, 3
product use method and, 54
worker characteristics and, xv–xvi
Finger and palm press method, 77, 78, 82–84
Fingernails and artificial nails, xix, 14, 17, 78–79
Focus groups, 63
Ontario Healthcare Worker Focus Group Guide, 130,
180–181
G
Germinators, 26
“Germs. Wash Your Hands of Them” campaign (HPS), xx,
91–92, 127
Global Patient Safety Challenge (WHO), xix, 87, 122
“Clean Care is Safer Care” initiative, xix, xxii, 81,
87–88, 122, 124
“Pilot Implementation Pack,” 88
Glossary of terms, xxvii–xxviii
Glove juice method, 78, 82, 84–85
Glove use
direct observation method of assessment, 21
hand hygiene guidelines on, 1, 80–81
IHI assessment recommendation, 21, 81
Information Sheet 6 on Glove Use (WHO), 81
Mayo Clinic Hand Hygiene and Glove Use Monitoring
Form, 32, 129, 145–146
protection provided by, 80–81
Gram-negative bacilli, 78, 80, 85
Greenview Regional Hospital accountability for hand
hygiene performance, 115
Greenville Hospital System
multiple methods to measure hand hygiene, 15–16
patient satisfaction surveys, 67
“Guide for Implementation” (WHO), 87–88
H
Hand hygiene
behavior
changing behavior, 107–108
elective, 108
inherent, 108
education and training on, 2, 73, 110
infection rates, relationship to, 96, 100–102, 103–105
misinformation and opinions about, xv–xvi
need for, xv
policies, procedures, and processes, 111–112
when to perform, xv
Hand hygiene guidelines. See also Adherence to hand
hygiene guidelines
behaviors addressed by, xvii, 1
CDC guidelines, xvii, 1
adherence rates and infection rates, relationship
between, 100
fingernails and artificial nails, 78
glove use, 1, 80–81
hand rubbing, 21
multidisciplinary programs, 110
rings and jewelry, 80
techniques for hand hygiene, 73
updates to, xxii
197
Index
WHO guidelines compared to, 6–11
differences and similarities across guidelines, 1, 6–11
education on, 73–75
importance of following, xxii, 1
issuing sources, 1
purpose of, 1
WHO guidelines, xvii, xxii, 1
adherence rates and infection rates, relationship
between, 96, 100
audit and feedback of adherence data, 110
CDC guidelines compared to, 6–11
fingernails and artificial nails, 78
glove use, 1, 80–81
microbiological methods for assessing thoroughness
of hand hygiene, 77–78
multidisciplinary programs, 110
rings and jewelry, 80
techniques for hand hygiene, 73, 74
update to, 96
Hand hygiene improvement strategy (WHO), 87–88
Hand Hygiene Knowledge Assessment Questionnaire
(IHI), 129, 155–156
Hand Hygiene Knowledge Test for Healthcare Workers
(WHO), 129, 152–154
Hand Hygiene Observation Tool (HHOT), xx, 23,
88–89, 129, 139–142
Hand Hygiene Resource Center (St. Raphael Healthcare
System), 128
“Hand Hygiene Saves Lives” video (CDC), 118, 121
Hand rubbing, 21, 73, 74
Hawthorne effect, 27–28, 29, 50–51, 90
Hawthorne Western Electric Plant, 28
Health Canada, 1. See also “Just Clean Your Hands”
program
Healthcare Associated Infection & Infection Control
Resource Centre (HPS), 91, 127
Health care-associated infections
adherence rates, relationship to, 96, 100–102, 103–105
causes of, xvi
hand hygiene and reduction of, xvi, 1
World Alliance for Patient Safety response to, xix
Healthcare Infection Control Practices Advisory
Committee (HICPAC), 121
Health Protection Scotland (HPS)
Compliance with Hand Hygiene Audit Report, 92
“Germs. Wash Your Hands of Them” campaign, xx,
91–92, 127
Healthcare Associated Infection & Infection Control
Resource Centre, 91, 127
HHOT (Hand Hygiene Observation Tool), xx, 23,
88–89, 129, 139–142
HICPAC (Healthcare Infection Control Practices Advisory
Committee), 121
Hospital of Saint Raphael, electronic counting device for
product use measurement, 56
How to Guide: Improving Hand Hygiene (IHI), 21, 31, 32,
121, 122
HPS. See Health Protection Scotland (HPS)
I
Ideal method, xxiii, 13, 19
IHI. See Institute for Healthcare Improvement (IHI)
Improvement interventions and initiatives, xx
accountability of staff, 114, 115
assessment of state of adherence before implementing,
109
changing behavior and, 107, 116, 118
factors that affect success of, 108–116
effective strategies, use of, 109–111, 112
external environment, 109, 116
organizational and system characteristics, 109,
111–114, 115
patient and families, involvement of, 109, 115–116,
118
personnel, 109, 114–115, 117
leadership’s commitment to, 113–114
models and strategies for, 107–108
quality improvement models and methods, 111, 112
resources for, xx, 121–128
success of, 116, 118
sustainability of, xxii
Improvement teams, 110
Incentives and rewards, 115, 117
Indications, hand hygiene, 2, 4. See also Opportunities,
hand hygiene
actions, relationship to, 20
198
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
measurement of, 14, 17
Infection Control Nurses Association, 91
Infection preventionists, xxviii, 25
Information Sheet 6 on Glove Use (WHO), 81
Inherent behavior, 108
Institute for Healthcare Improvement (IHI), 121–122,
123
central line infections bundle, 102
CMHH project, xxi
glove use and removal assessment, 21, 81
hand hygiene competence assessment, 21
Hand Hygiene Knowledge Assessment Questionnaire,
129, 155–156
hand hygiene observation and monitoring, 73
How to Guide: Improving Hand Hygiene, 21, 31, 32,
121, 122
quality improvement models and methods, 111, 112
teams, multidisciplinary, 110
Web site, xx
Interrater reliability (interobserver reliability), 29, 30
Item-by-item measures and calculations, 30, 32
“It’s OK to Ask” study, 116
J
Jewelry and rings, xix, 14, 17, 80
Jewish Hospital
adherence rates and infection rates, relationship
between, 101
staff as observers, 26
Joint Commission
CMHH project, xxi–xxii
hand hygiene adherence initiatives, 122, 125
National Patient Safety Goal 7, xvii, xxii, 2
requirements of and improvement initiatives, 116
Joint Commission Resources, 125
Judgement sampling, 49
“Just Clean Your Hands” program, xx, 23, 89–90, 126
Ontario Assessment Tool for Health Care Provider
Hands, 130, 187–192
Ontario Baseline Hand Hygiene Perception Survey,
130, 162–164
Ontario Baseline Hand Hygiene Unit Structure Survey,
130, 169–170
Ontario Facility-Level Situation Assessment, 130,
171–174
Ontario Healthcare Worker Focus Group Guide, 130,
180–181
Ontario Observation Tool, 89–90, 129, 137–138
Ontario Patient Discharge Questionnaire, 130,
175–179
Quick Guide to “Just Clean Your Hands”, 109, 111,
113–114
reminders, visual, 110
stratified rates, 95
success, definition of, 116
training associated with, 29
L
Leadership, commitment to improvement by, 113–114
Liberty Hospital, staff as observers, 26
Local opinion leaders, 111
M
“Managing Toward Daily Compliance” initiative, 112
Manual for Observers (WHO), 2, 23, 28, 88
Marketing theoretical model, 108
Mayo Clinic
all-or-none calculation method, 32
Hand Hygiene and Glove Use Monitoring Form, 32,
129, 145–146
MDRO (multiple-drug-resistant organism) infections,
90–91
Measurement of adherence
actions, 2
CDC guidelines and, xxii
challenges of, xvii, xxii–xxiii
CMHH project, xxii
elements to measure, 13–14, 17
evidence-based guidelines, xxi
indications, 2, 4
methods of (see also Direct observation method;
Product use method; Surveys)
advantages and limitations of, xvi, xviii, 14, 18
ideal method, xxiii, 13, 19
multiple methods, use of, 15–16, 53, 61–62
reliability of, xxii, xxiii
199
Index
selection of, xvii–xviii, 13–18
opportunities, 2
organizational goals for, 13
reliability of statistics on, xvi
resources for, 121–128
strategy for, 3, 13–18
tools for, xix–xx, xxi
WHO guidelines and, xxii
Methicillin-resistant Staphylococcus aureus (MRSA), 88, 91,
111, 115
Methodist Hospital secret shopper program, 28
Microbiological methods for assessing thoroughness of
hand hygiene, 77–78, 82–85
Moments for hand hygiene, 2, 4, 20
Moses Cone Health System accountability for hand
hygiene performance, 115
MRSA (methicillin-resistant Staphylococcus aureus), 88, 91,
111, 115
Multidisciplinary teams, 110
Multiple-drug-resistant organism (MDRO) infections,
90–91
N
National Committee for Quality Assurance, 116
National Foundation for Infectious Diseases (NFID), xx,
xxi, 122, 123
National Health Service, England, 1
National Observation Study to Evaluate the “cleany-
ourhands” Campaign (NOSEC), xix–xx, 88–89, 126
National Patient Safety Agency (NPSA)
“cleanyourhands” campaign, xix–xx, 88, 126
Hand Hygiene Observation Tool (HHOT), xx, 23,
88–89, 129, 139–142
National Observation Study to Evaluate the “cleany-
ourhands” Campaign (NOSEC), xix–xx, 88–89, 126
National Patient Safety Goal 7, xvii, xxii, 2
New South Wales Department of Health “Clean Hands
Save Lives” campaign, xx, 90–91, 127
data collection tool, 90
NFID (National Foundation for Infectious Diseases), xx,
xxi, 122, 123
Non-probability sampling, 49
NOSEC (National Observation Study to Evaluate the
“cleanyourhands” Campaign), xix–xx, 88–89, 126
“Nurse Pride” program, 117
O
Observation Audit Tool, 75, 76–77
Observation method. See Direct observation method
Observation Tool and Calculation Form (WHO), 129,
131–134
Ontario, Canada’s “Just Clean Your Hands” program. See
“Just Clean Your Hands” program
Ontario Assessment Tool for Health Care Provider Hands,
130, 187–192
Ontario Baseline Hand Hygiene Perception Survey, 130,
162–164
Ontario Baseline Hand Hygiene Unit Structure Survey,
130, 169–170
Ontario Facility-Level Situation Assessment, 130, 171–174
Ontario Healthcare Worker Focus Group Guide, 130,
180–181
Ontario Observation Tool, 89–90, 129, 137–138
Ontario Patient Discharge Questionnaire, 130, 175–179
Opportunities, hand hygiene, 2. See also Indications, hand
hygiene
actions, relationship to, 20
adherence rates
opportunities measured and, 20, 34–35
patient mix and intensity of patient care and, 20,
36–40, 55
measurement of, 14, 17, 19, 92
moments for hand hygiene, 2, 4, 20
product use method and, 54
Organizational and system characteristics, 109, 111–114
Organizational goals for measurement, 13
Organizational theoretical model, 108
Osaka University video camera surveillance, 28–29
Overt Observational Instructions and Tool, 129, 147–151
Overt versus covert observation, 26–28, 50–51
P
Palm and finger press method, 77, 78, 82–84
Park Nicollet Methodist Hospital, display and reporting of
adherence rates, 97–98
200
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Patient and families
data collection by for observation method, 25–26, 27
education of, 118
improvement interventions and initiatives, 109,
115–116, 118
observation of hand hygiene behavior of, 22
privacy considerations, 28
product use intervention, participation in, 54
satisfaction of
case studies and examples, 15–16
Ontario Patient Discharge Questionnaire, 130,
175–179
surveys to measure, 14, 17, 66, 67, 69–70
Patient mix and intensity of patient care, 20, 36–40
Performance improvement models and methods, 111
Cleveland Clinic, 112
Veterans Affairs Medical Centers, 112
“Pilot Implementation Pack” (WHO), 88
Planned Behavior, 108
Policies, adherence to, 14, 17
Positive deviance, 111
Privacy considerations, 28
Probability sampling, 49
Products, types used, 20
Product use method
accuracy of, 54
adherence rates, calculating, 58–59
advantages and limitations of, xvi, xviii, 18, 53–54
alcohol-based hand rubs, 53
benchmarking through product measurement system,
60
data collection, xix, 54–55
description of, 14, 18, 53
direct observation method and, 15, 53–54, 61–62
electronic counting devices, 55–57
electronic monitoring systems, 57–58
elements to measure, 14, 17
amount of product used, 54–55, 56
frequency of product use, 55–58
patient participation in intervention, 54
reliability of, xviii
Veterans Administration National Center for Patient
Safety, alcohol-based hand rub spreadsheets, 58, 128
Proportional sampling, 49
Q
Quality improvement models and methods, 111, 112
Questionnaire on the Perception of Hand Hygiene and
Health Care-associated Infections for Senior Executive
Managers (WHO), 130, 160–161
Questionnaire on Ward Structures for Hand Hygiene
(WHO), 130, 167–168
Quota sampling, 49
R
Random sampling, 49
Recall bias, 64
Reedsburg Area Medical Center Observation Tool, 129,
143–144
Reliability among observers, 29
Reminders, visual and auditory, 110
Resources for measurement and improvement, 121–128
Rewards and incentives, 115, 117
Rings and jewelry, xix, 14, 17, 80
Rogue Valley Medical Center, staff as observers, 26
S
Safe Care Campaign, 128
Safety culture, 114
“Safety First” program, 117
Sampling strategies, 24–25, 49
Satisfaction with practices, 14, 17
Scotland. See Health Protection Scotland (HPS)
Self-reporting of hand hygiene, xix
Semmelweis Project, 27
SHEA (Society for Healthcare Epidemiology of America),
xx, xxi, 122, 124
Shriners Hospital for Children
patient hand hygiene behavior at Chicago hospital, 22
product use method at Erie hospital, 55
Simple random sampling, 49
Six Sigma, 112
Skin condition, self-assessment, 66, 69–70
Evaluation of tolerability and acceptability of alcohol-
based hand rub (WHO), 130, 182–186
201
Index
Ontario Assessment Tool for Health Care Provider
Hands, 130, 187–192
Soap and water, techniques for using, 73, 74
Social influence theoretical model, 108
Society for Healthcare Epidemiology of America (SHEA),
xx, xxi, 122, 124
Spartanburg Regional Healthcare System
display and reporting of adherence rates, 99
fingernails and artificial nails policy, 79
multiple methods to measure hand hygiene, 15
patient education and involvement, 118
patient satisfaction surveys, 67
staff incentives and rewards program, 117
Speak Up! campaign (Joint Commission), 125
Staff
accountability of, 114, 115
adherence rates by discipline, 21–22, 40–42, 65–66
data collection by for observation method, 25, 26
focus groups, 63
Ontario Healthcare Worker Focus Group Guide,
130, 180–181
improvement interventions and initiatives, 109,
114–115, 117
knowledge, attitudes, and perceptions
competence reviews for staff and hand hygiene, 21
IHI assessment recommendation, 21
measurement of, 14, 17
structural considerations and, 15
surveys to measure, 63–64, 65, 69–72, 129–130,
152–166
knowledge, attitudes, and perceptions, survey examples
Attitudes Regarding Practice Guidelines, 130,
165–166
Baseline Questionnaire of the Perception of Hand
Hygiene and Health Care-associated Infections for
Health-care Workers (WHO), 130, 157–160
Hand Hygiene Knowledge Assessment Questionnaire
(IHI), 129, 155–156
Hand Hygiene Knowledge Test for Healthcare
Workers (WHO), 129, 152–154
Ontario Baseline Hand Hygiene Perception Survey,
130, 162–164
Questionnaire on the Perception of Hand Hygiene
and Health Care-associated Infections for Senior
Executive Managers (WHO), 130, 160–161
privacy considerations, 28
rewards and incentives, 115, 117
satisfaction surveys, 14, 17, 66, 71
Evaluation of tolerability and acceptability of
alcohol-based hand rub (WHO), 130, 182–186
self-perceptions, surveys to measure, 65–66, 69–72
skin condition, self-assessment, 66, 69–70
Statistical process control charts, xx, 95, 100
St. Clare’s Hospital fingernails and artificial nails policy, 79
St. Joseph Hospital commitment of leadership, 113
St. Joseph Medical Center, patient education and involve-
ment, 118
“STOP! Clean Your Hands” campaign (Canadian Patient
Safety Institute), 89, 127
St. Raphael Healthcare System, 128
Stratified proportional sampling, 49
Stratified random sampling, 49
Structural considerations
improvement interventions and initiatives, 111
measurement of, 14, 17
observation method and, 14, 19
staff knowledge and, 15
survey examples
Ontario Baseline Hand Hygiene Unit Structure
Survey, 130, 169–170
Ontario Facility-Level Situation Assessment, 130,
171–174
Questionnaire on Ward Structures for Hand Hygiene
(WHO), 130, 167–168
surveys to measure, 66, 69–72
Surgical site infections, 102
Surveys
accuracy of, 64
additional information about, 64
administration methods, 14, 63
advantages and limitations of, xix, 18, 63–64
bias, 64
data collection, xix
description of, 14, 18
elements to measure, 14, 17, 64–66
202
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
attitudes and perceptions, 65, 69–72, 129–130,
152–166
patient and families satisfaction, 66, 67, 69–70
self-perceptions, 65–66, 69–72
skin condition, self-assessment, 66, 69–70
staff knowledge, 65, 69–72, 129–130, 152–166
staff satisfaction, 66, 71
structural considerations, 66, 69–72
examples of, 69–72, 129–130, 152–192
examples of, knowledge and attitudes
Attitudes Regarding Practice Guidelines, 130,
165–166
Baseline Questionnaire of the Perception of Hand
Hygiene and Health Care-associated Infections for
Health-care Workers (WHO), 130, 157–160
Hand Hygiene Knowledge Assessment Questionnaire
(IHI), 129, 155–156
Hand Hygiene Knowledge Test for Healthcare
Workers (WHO), 129, 152–154
Ontario Baseline Hand Hygiene Perception Survey,
130, 162–164
Questionnaire on the Perception of Hand Hygiene
and Health Care-associated Infections for Senior
Executive Managers (WHO), 130, 160–161
examples of, patient satisfaction
Ontario Patient Discharge Questionnaire, 130,
175–179
examples of, skin condition
Evaluation of tolerability and acceptability of
alcohol-based hand rub (WHO), 130, 182–186
Ontario Assessment Tool for Health Care Provider
Hands, 130, 187–192
examples of, staff satisfaction
Evaluation of tolerability and acceptability of
alcohol-based hand rub (WHO), 130, 182–186
examples of, structural considerations
Ontario Baseline Hand Hygiene Unit Structure
Survey, 130, 169–170
Ontario Facility-Level Situation Assessment, 130,
171–174
Questionnaire on Ward Structures for Hand Hygiene
(WHO), 130, 167–168
focus groups, 63
Ontario Healthcare Worker Focus Group Guide,
130, 180–181
purpose of, 63
reliability of, xix
response rate, 64
validity of, 64
Swab method, 77, 78, 85
“swisshandhygiene” campaign, 127
T
Teams, multidisciplinary, 110
Techniques, hand hygiene
amount of time and thoroughness of cleansing, 73
assessment of, xix, 75
audit and feedback on, 110
competence reviews for staff and, 21
education on, 73–75
hand rubbing, 21, 73, 74
observation and monitoring of, 73, 75
Observation Audit Tool, 75, 76–77
policies, procedures, and processes, 111–112
thoroughness of cleansing, 20–21, 73
microbiological methods for assessing, 77–78, 82–85
physical measurement of, 75, 77
training on, xix
Technology, direct observation method and, 28–29
Thoroughness of cleansing, 20–21, 73
microbiological methods for assessing, 77–78, 82–85
physical measurement of, 75, 77
Three Rivers Community Hospital, staff as observers, 26
Towels, 1, 21
Triangulation, 15
Tripler Army Medical Center, patients as observers, 27
U
Unit- and discipline-level reporting, 95, 97–99
University Community Hospital, fingernails and artificial
nails policy, 79
University of Geneva Hospitals, 127
University of Louisville Hospital all-or-none measures and
calculations, 32
Urinary tract infections, 102
203
Index
V
Veterans Administration National Center for Patient
Safety, alcohol-based hand rub spreadsheets, 58, 128
Veterans Affairs, Department of, 128
Veterans Affairs Medical Centers
electronic counting device for product use measure-
ment, 56
positive deviance, 111
Six Sigma, 112
Video cameras, 28–29
Visual reminders, 110
W
Wales. See England and Wales
WAPS (World Alliance for Patient Safety), xix, xxi
Web sites
Association for Professionals in Infection Control and
Epidemiology, Inc. (APIC), xx, 121, 123
Canadian Patient Safety Institute “STOP! Clean Your
Hands” campaign, 127
Centers for Disease Control and Prevention (CDC), xx,
121, 123
central line infections bundle (IHI), 102
“Clean Hands Save Lives” campaign, xx, 127
“cleanyourhands” campaign, xix, 88, 126
Collaborating Centre for Patient Safety Solutions
(WHO), 125
“Germs. Wash Your Hands of Them” campaign, xx, 91
Hand Hygiene Observation Tool (HHOT), 23, 89
Hand Hygiene Resource Center (St. Raphael
Healthcare System), 128
“Hand Hygiene Saves Lives” video (CDC), 118
Healthcare Associated Infection & Infection Control
Resource Centre, 91
Institute for Healthcare Improvement (IHI), xx, 122,
123
Joint Commission Resources, 125
“Just Clean Your Hands” program, xx, 23, 89, 110, 126
National Foundation for Infectious Diseases (NFID),
xx, 122, 123
National Observation Study to Evaluate the “cleany-
ourhands” Campaign (NOSEC), xix–xx, 89, 126
reminders, visual, 110
Safe Care Campaign, 128
Society for Healthcare Epidemiology of America
(SHEA), xx, 122, 124
Speak Up! campaign (Joint Commission), 125
“swisshandhygiene” campaign, 127
University of Geneva Hospitals, 127
Veterans Administration National Center for Patient
Safety, alcohol-based hand rub spreadsheets, 58, 128
Veterans Affairs, Department of, 128
World Health Organization (WHO), xx, 124
World Alliance for Patient Safety (WAPS), xix, xxi, 122,
124
World Health Organization (WHO), 122, 124
Baseline Questionnaire of the Perception of Hand
Hygiene and Health Care-associated Infections for
Health-care Workers, 130, 157–160
“Clean Care is Safer Care” initiative, xix, xxii, 81,
87–88, 122, 124
CMHH project, xxi
Collaborating Centre for Patient Safety Solutions, 125
Evaluation of tolerability and acceptability of alcohol-
based hand rub, 130, 182–186
Global Patient Safety Challenge, xix, 87, 122
Pilot Implementation Pack, 88
gold standard for measuring adherence, 19
“Guide for Implementation,” 87–88
hand hygiene and reduction of infections, xvi
hand hygiene guidelines, xvii, xxii, 1
adherence rates and infection rates, relationship
between, 96, 100
audit and feedback of adherence data, 110
CDC guidelines compared to, 6–11
fingernails and artificial nails, 78
glove use, 1, 80–81
microbiological methods for assessing thoroughness
of hand hygiene, 77–78
multidisciplinary programs, 110
rings and jewelry, 80
techniques for hand hygiene, 73, 74
update to, 96
hand hygiene improvement strategy and initiatives, 2,
87–88
204
MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES
Hand Hygiene Knowledge Test for Healthcare Workers,
129, 152–154
Information Sheet 6 on Glove Use, 81
Manual for Observers, 2, 23, 28, 88
measurement tool examples
Basic Hand Hygiene Observation Tool, 129,
135–136
Observation Tool and Calculation Form, 129,
131–134
moments for hand hygiene, 2, 4, 20
opportunities, hand hygiene, 20
Questionnaire on the Perception of Hand Hygiene and
Health Care-associated Infections for Senior Executive
Managers, 130, 160–161
Questionnaire on Ward Structures for Hand Hygiene,
130, 167–168
Web site, xx
World Alliance for Patient Safety, xix, xxi
Y
Yale New Haven Hospital, electronic counting device for
product use measurement, 56